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Back to Basics 2013. Dr. Brian Weitzman Department of Emergency Medicine Ottawa Hospital. Review of 14 Common Emergency Medicine Topics. Today Acute Abdominal Pain Acute Dyspnea Hypotension/Shock Syncope Coma Cardiac Arrest. Other Emergency Medicine Topics .

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back to basics 2013

Back to Basics2013

Dr. Brian Weitzman

Department of Emergency Medicine

Ottawa Hospital

review of 14 common emergency medicine topics
Review of 14 Common Emergency Medicine Topics


  • Acute Abdominal Pain
  • Acute Dyspnea
  • Hypotension/Shock
  • Syncope
  • Coma
  • Cardiac Arrest
other emergency medicine topics
Other Emergency Medicine Topics
  • Malignant Hypertension
  • Animal Bites
  • Burns
  • Near-drowning
  • Hypothermia
  • Poisoning
  • Urticaria/Anaphylaxis
abdominal pain mcc objectives
Abdominal PainMCC Objectives
  • Common causes of pain
    • Localized -Upper vs Lower Abdominal
    • Diffuse
  • History –list and interpret clinical finding
  • Physical exam: appropriate-vitals, abd, rectal, pelvic GU
    • -recognize peritonits
  • Investigate: order appropriate tests
  • Interpret clinical and lab data
  • Management plan:
    • Who needs immediate attention and treatment/surgery
    • Non-emergency management
    • Further investigation or specialized care
case 1
Case 1:

Sally is an 18 year old woman who presents with a 2 day history of dull periumbilical pain which now localizes to the RLQ.

What disease process is this typical for?

What causes the change in the pain pattern?

What other diseases must you consider?

neurologic basis of abdominal pain
Neurologic Basis of Abdominal Pain
  • Visceral
  • Somatic
  • Referred
visceral abdominal pain
Visceral Abdominal Pain
  • Stretch receptors in walls of organs
  • Stimulated by distention, inflammation
  • return to spinal cord: bilateral, multiple levels
  • Brain cannot localize source
visceral abdominal pain1
Visceral Abdominal Pain
  • Pain felt as crampy, dull, achy, poorly localized
  • Associated with autonomic responses of palor, sweating, nausea, vomiting
  • Patients often writhing around
    • Movement doesn’t alter pain
somatic abdominal pain
Somatic Abdominal Pain
  • parietal peritoneum
  • Returns to ipsilateral dorsal root ganglion at 1 dermatomal level
  • Sharp, localized pain
  • Causes tenderness, rebound, and guarding
  • Patients lie still, movement increases pain
referred pain
Referred Pain
  • What is it?
  • What are some examples?
referred pain1
Referred Pain
  • Pain perceived in an area that is distant from the disease process
  • Due to overlapping nerve innervations
examples of referred pain
Examples of Referred Pain
  • Shoulder pain with diaphragm stimulation
    • C 3,4,5 stimulation
  • Back pain with biliary colic, pancreatitis, or PID
differential diagnosis
Differential Diagnosis
  • Diffuse vs Localized
diffuse abdominal pain
Diffuse Abdominal Pain
  • Peritonitis
  • AAA
  • Ischemic Bowel
  • Gastroenteritis
  • Irritable Bowel Syndrome
causes of abd pain localized
Causes of Abd Pain - Localized

Upper Abdominal

Lower Abdominal

localized abdominal pain
Localized Abdominal Pain




  • Biliary Colic/Cholecystitis
  • Hepatitis / Hepatic Abscess
  • Pneumonia / Pleurisy
  • Splenic Infarction
  • Splenic Rupture
  • Pneumonia

Incarcerated Hernia

Bowel obstruction

Inflammatory bowel disease



Ovarian(torsion or cystA)


Renal Stones/UTI

Testicular torsion

  • Appendicitis
  • Mesenteric lymphadenitis
case 11
Case 1:

Sally is an 18 year old woman who presents with a 2 day history of dull periumbilical pain which now localizes to the RLQ.

case 1 questions
Case 1: Questions

1. What further history do you need from the patient?

2. What would you do in your physical exam?

3. What are you looking for on physical examination?

4. What initial stabilization is required?

5. What is your differential diagnosis?

  • Onset / Duration
  • Nature / Character / Severity
  • Radiation
  • Exacerbating / Relieving Factors
  • Location
  • Associated Symptoms
    • Nausea / Vomiting
    • Diarrhea / Constipation / Flatus
    • Fever
    • Jaundice / other skin changes
    • GU (dysuria, freq, urgency, hematuria…)
    • Gyne (menses, contraception, STDs,,,)
  • PMHx
    • Prior Surgery
    • Medical Problems
  • Medications
high yield questions1
High Yield Questions
  • 1. Age Advanced age means increased risk.
  • Which came first—pain or vomiting?
    • Pain first is worse (i.e., more likely to be caused by surgical disease).
  • 3. When did it start? Pain for < 48 hrs is worse.
  • 4. Previous abdominal surgery? Consider obstruction.
  • 5. Is the pain constant or intermittent? Constant pain is worse.
  • 6. Previous hx of pain?
  • 7. Pregnant? consider ectopic.
high yield questions cont d
High Yield Questions cont’d
  • History of serious illness is suggestive of more serious disease.
  • HIV? Consider occult infection or drug-related pancreatitis.
  • Alcohol? Consider pancreatitis, hepatitis, or cirrhosis.
  • 11. Antibiotics or steroids? These may mask infection.
  • 12. Did the pain start centrally and migrate to the right lower quadrant? High specificity for appendicitis.
high yield questions cont d1
High Yield Questions, cont’d

13. History of vascular or heart disease, hypertension, or atrial fibrillation? Consider mesenteric ischemia and abdominal aneurysm.

physical examination1
Physical Examination
  • Vitals
  • General appearance: writhing/motionless, diaphoresis, skin, mental status
  • Always do brief cardiac and respiratory exam
  • Abdominal exam: Look, listen, feel
  • Pelvic, genital and rectal exam in ALL patients with severe abdominal pain
  • Assess pulses!
abdo exam specifics
Abdo Exam: Specifics
  • Always palpate from areas of least pain to areas with maximal pain
  • ?Organomegaly, ?ascites
  • Guarding: voluntary vs. involuntary
  • Bowel sounds: increased/decreased/absent
  • Rectal exam: occult/frank blood, ?stool, ?pain, ?masses
  • Pelvic exam: discharge, pain, masses
  • Peritonitis:
    • suggested by: rigidity with severe tenderness, pain with percussion/deep breath/shaking bed, rebound
risk factors for acute disease
Risk Factors for Acute Disease
  • Extremes of age
  • Abnormal vital signs
  • Severe pain of rapid onset
  • Signs of dehydration
  • Skin pallor and sweating
initial stabilization1
Initial Stabilization
  • All patients with acute abdominal pain:
  • Assess vital signs
  • Oxygen
  • Cardiac Monitoring/12 lead ECG
  • Large bore IV (may need 2)
    • 250-500 cc bolus of NS in elderly with low BP
    • 500-1000 cc bolus in younger patients with low BP
  • Consider NG and Foley catheter
  • Brief initial examination : history and physical
  • Consider analgesics
  • ??Do they need immediate surgical consultation?
pain er management
Pain: ER Management
  • Is it OK to give a patient pain medications before you determine their diagnosis?
abdominal pain er management
Abdominal Pain: ER Management
  • Anti-inflammatories (NSAIDs):
    • very effective, esp. for MSK or renal colic pain
    • Ex. Ketorlac (Toradol) 30 mg IV
  • Narcotics
    • sc/im/iv
    • very effective, esp. for visceral or undifferentiated pain
    • Ex. Morphine 2.5-5 mg, hydromorphone 1-2 mg
nausea vomiting er tx1
Nausea/Vomiting: ER Tx
  • Ondansetron (Zofran) : iv 4-8 mg
    • very useful in patients with refractory vomiting
  • Dimenhydrinate (Gravol): po/pr/im/iv 25-50 mg
    • beware of anticholinergic side effects
    • sedating, may cause confusion
  • Metoclopramide (Maxeran) 10 mg IV
  • Prochlorperazine (Stemetil): 10 mg IV
    • beware of possible EPS
    • less sedating; may help with pain control
  • Domperidone: po/iv
    • especially useful with diabetic gastroparesis
  • Most patients with acute abdominal pain require:
  • - CBC, differential; may need type and cross-match
  • electrolytes, BUN, creatinine,
  • lactate
  • - liver function tests
  • - lipase
  • - beta-hCG
  • - urinalysis; stool for OB
  • They may also need: ECG, cardiac enzymes, ABG,



CT scan

plain Xrays


A 73 y.o. man presents to the ED with left lower abd pain to left flank x 5 hours. PMH: Hypertension. Abdomen is diffusely tender. No rebound/ guarding. P 120 BP 95/70 RR 18 T 37.5 02 95%

  • What is the most likely diagnosis?

1) Diverticulitis

2) Renal colic

3) Ischemic bowel

4) Pyelonephritis

5) Other


A 73 y.o. man presents to the ED with left lower abd pain to left flank x 5 hours. PMH: Hypertension. Abdomen is diffusely tender. No rebound/ guarding. P 120 BP 95/70 RR 18 T 37 02 95%

  • What is your immediate treatment?
  • What investigations will you do?

A 45 y.o. man presents to the ED with left lower abd pain to left flank x 5 hours.. Abdomen is mildly tender L side. No rebound/ guarding. P 120 BP 130/70 RR 18 T 37 02 98%

  • What is your diagnosis?
  • What is your immediate treatment?
  • What investigations will you do?

A 75 y.o. man presents with 6 hours of LLQ pain which has become more diffuse. T 38, P 120, BP 130/60What is the cause of this man’s pain?

what is the cause of this man s pain
What is the cause of this man’s pain?
  • Double lumen sign of free air in abdomen
  • Perforated diverticulitis

Small Bowel Obstruction

  • Central location, plica circularis (valvulae coniventes)
  • Stacked coin appearance

Plica circularis

Air fluid levels

what are the 3 leading causes of sbo
What are the 3 leading causes of SBO
  • 1) adhesions
  • 2) hernia
  • 3) neoplasm
3 leading causes of lbo
3 Leading causes of LBO
  • 1) neoplasm
  • 2) Diverticulitis
  • 3) volvulus
sigmoid volvulus
Sigmoid Volvulus

massive bowel dilation

single loop “bent rubber tube”

34yr female: cerebral palsy, no BM’s, abdo distension

34 y.o. man, alcoholic binge, repeated vomiting. Now abdominal pain, guarding rebound. What is the cause of this man’s abdominal
summary approach to abdominal pain in the er
Summary: Approach to Abdominal Pain in the ER
  • ABC assessment
  • Stabilize the patient, and refer early if unstable
  • Careful, detailed history
  • Focused physical examination
  • Early, thorough work-up:
    • Appropriate laboratory investigation
    • Diagnostic imaging where indicated
  • Continuous reassessment
  • Consider patient circumstances (age, pmhx, reliability, home situation)
summary common causes of abdominal pain mcc categorization
Summary: Common Causes of Abdominal PainMCC Categorization
  • Is it diffuse or localized?
  • Do they need immediate resuscitation, referral or surgery?
acute dyspnea minutes to hours mcc objectives
Acute Dyspnea (minutes to hours)MCC Objectives
  • Differentiate cardiac, pulmonary, central causes
  • Assess the A, B, C’s
  • Diagnose and manage acute dyspnea
  • Identify life threatening dyspnea
  • Interpret clinical and lab data
    • ECG, ABG, chest xray
  • Management: acutely, refer prn, plan long-term Rx if chronic
what drives us to breath
What drives us to breath?
  • Chemoreceptors in medulla, carotid and aortic bodies:
    • High CO2
    • High H+ ion
    • Low 02.
  • Stretch and baroreceptors in lungs
  • Dyspnea:
    • sensation of shortness of breath
  • Tachypnea:
    • rapid, shallowing breathing
  • Hyperventilation:
    • breathing in excess of metabolic needs of body lowering C02
    • Need to rule out organic disease
A 55 year old woman comes into the ED in obvious respiratory distress. She is very agitated, sitting forward, using her accessory muscles.

What is her problem?

most common causes of acute dyspnea mcc
Most Common Causes of Acute Dyspnea (MCC)
  • Cardiac:
    • MI
    • Valvular heart disease
    • Pericardial Tamponade
    • Dysrhythmia
    • Increased cardiac output (anemia)
acute dyspnea pulmonary causes
Acute Dyspnea-Pulmonary Causes
  • Upper airway: Aspiration, anaphylaxis, FB,
  • Chest wall and pleura (effusion, pneumothorax)
  • Lower airway: COPD, asthma
  • Alveolar: pneumonia, CHF
  • Vascular Resistance, hypoxia: PE
acute dyspnea
Acute Dyspnea
  • Central causes
    • Metabolic: acidosis, ASA toxicity
rapid assessment
Rapid Assessment
  • ABC’s : 5 vitals: P, RR, BP, T, 02 sat.
  • O2, IV, Monitor, ECG
rapid assessment general
Rapid Assessment-General
  • Ability to speak
  • Mental status, agitation, confusion
  • Positioning
  • Cyanosis:
    • Central: Hgb desats by 5 g. Not evident in anemia
    • Peripheral: mottled extremities
rapid assessment1
Rapid Assessment
  • Airway:
    • Is the patient protecting it?
      • Talking, swallowing, gagging
    • Is the patient able to oxygenate and ventilate adequately?
    • Is there stridor
  • Nasal prongs max. 4-5l/min
    • Increase FIO2 by 4%/L
  • Venturi: up to 50%
  • 02 reservoir: 90-95%
5 reasons to intubate
5 Reasons to Intubate
  • Protection
  • Creation
  • Oxygenation
  • Ventilation
  • Pulmonary toilet
  • Look, listen, feel, or IPPA
  • Wheezes, rales, rubs, decreased air entry
  • Is it adequate? O2 sat?
  • Pulse, BP,
  • Heart sounds ? Muffled
  • JVP
  • Edema
rapid assessment2
Rapid Assessment
  • Does this person need immediate treatment?
  • Ventolin
  • Nitroglycerin
  • ASA
  • Furosemide
  • BiPap
  • Needle decompression
history what are the key questions
History-What are the key questions?
  • Previous hx of similar event
  • How long SOB
  • Onset gradual or sudden
  • What makes it better or worse
  • Associated symptoms:
    • Chest pain, cough, fever, sputum, PND, orthopnea, SOBOE
history what are the key questions1
History-What are the key questions?
  • Medications, home 02
  • Allergies
  • What has helped in the past
  • Past medical history:
    • Cardiac, pulmonary, recent surgery
labs investigations
  • CBC, Lytes, Cardiac enzymes
  • D dimer
  • ECG
  • Pulmonary Function Tests
  • CXR
  • Helical CT
  • Pulmonary angiogram
  • V/Q –Nuclear ventilation perfusion scan

hyperlucent lung fields

increased retrosternal air

low set diaphragm

increased AP diameter

flat diaphragm

vertical heart

72yr female: chronic SOB, worse x few days

principles of management copd
Principles of ManagementCOPD
  • Oxygen
    • Titrate with 02 sat:
    • Monitor pC02, avoid loss of hypoxic drive
  • Beta agonists and anticholinergics
    • Ventolin 1 cc in 2 cc atrovent or MDI
  • Steroids ex. Solumedrol 125 mg IV
  • BiPap
  • Antibiotics
status asthmaticus
Status Asthmaticus
  • 100 % oxygen
  • continuous ventolin in atrovent
  • Prednisone P.O. or solumedrol IV
  • magnesium S04 2 gm over 2 min
  • Epinephrine IM or IV has limited role
rml pneumonia
RML pneumonia

diaphragm preserved

R heart border obscured

lat confirms ant location

46yr male: chills, pleuritic C/P, ant R creps

lll pneumonia
LLL pneumonia

58yr female: weakness, cough, SOB

lll pneumonia1
LLL pneumonia

lat confirms post location

diaphragm obscured

58yr female: weakness, cough, SOB

principles of management pneumonia
Principles of ManagementPneumonia
  • Oxygen to maintain 02 sat at 92-94%
  • Antibiotics:
    • Macrolides
    • Fluroquinolones
    • 2nd or 3rd generation cephalosporin
  • Beta agonists and BiPap as required
  • Considering scoring system for disposition
    • CURB-65, CRB-65, Pneumonia Severity Index
pulmonary edema
Pulmonary edema

increased cephalic blood flow

increased periph blood flow

alveolar infiltrates

Kerley B lines

prominent hilar vessels


69yr male: past MI, SOB, orthopnea, PND

principles of management pulmonary edema
Principles of ManagementPulmonary Edema
  • Lasix –furosemide 40-160 mg IV
  • Morphine 2-4 mg IV
  • Nitroglycerin SL, IV
  • Oxygen
  • Position, postive pressure BiPap
  • ECG-rule out ACS
principles of management pneumothorax
Principles of ManagementPneumothorax
  • Tension: 14 gauge needle 2nd ICS, MCL
      • 30 Fr chest tube
  • Pigtail catheter
  • Small spontaneous pneumothorax: @20%
    • May observe, discharge, repeat CXR 24 hrs
ruptured aorta
Ruptured Aorta

widened superior mediastinum

loss of aortic knuckle

34yr male: MVC hit tree, unrestrained, c/o chest pain

a 75 y o with a history of chf comes in drowsy gasping for air
A 75 y.o. with a history of CHF comes in drowsy, gasping for air. :
  • pH 7.15
  • pC02 70
  • HCO3 30
  • P02 60
  • Diagnosis
  • Acute or Chronic
a 75 y o with a history of chf comes in drowsy gasping for air1
A 75 y.o. with a history of CHF comes in drowsy, gasping for air. :
  • pH 7.15
  • pC02 70
  • HCO3 30
  • P02 60
  • Acute Respiratory Acidosis
    • pH is low
    • HCO3 has not had time to increase
a 75 y o with copd and dyspnea x 2 days
A 75. y.o. with COPD and dyspnea x 2 days
  • pH 7.32
  • pC02 80
  • HC03 40
  • p02` 65
  • Acute or Chronic
a 75 y o with copd and dyspnea x 2 days1
A 75. y.o. with COPD and dyspnea x 2 days
  • pH 7.32
  • pC02 80
  • HC03 40
  • p02` 65
  • Chronic Respiratory Acidosis
    • HC03 very high therefor pH not that low despite C02 of 80
a 25 y o diabetic vomiting x 2 days looks dyspneic1
A 25 y.o. diabetic, vomiting x 2 days, looks dyspneic
  • pH 7.10
  • HC03 10
  • pC02 18
  • P02 95
  • Acute metabolic acidosis, and partially compensating respiratory alkalosis
an anxious individual
An anxious individual
  • A 55 y.o. woman, recent fatigue, shortness of breath, comes in to the ED hyperventilating. Feels more short of breath x 1 hour .
  • What will you do?
ischemic symptoms in women
Ischemic Symptoms in Women




Often no chest pain (vs men)

admission criteria for dyspnea
Admission Criteria for Dyspnea
  • Older patient
  • Abnormal vitals including 02 sat
  • Abnormal level of consciousness
  • Significant illness ex. Pneumonia
  • Patient fatigue
  • No improvement despite treatment
  • Home situation
syncope mcc objectives
Syncope-MCC Objectives
  • Definition
  • Distinguish from Seizure
  • Causes: serious or not, cardiac or not
  • ‘Targeted’Hx, Px, Investigations
  • Initial Management Plan
  • Who needs referral, fitness to drive
  • A 73 y.o. man collapsed in the bathroom and had a 30 second episode of unresponsiveness at 0430. He awakes fully, and is brought to the Emergency Department by his wife.
  • Is this a syncopal episode?
  • What are the causes of syncope?
  • What is the likelihood he had a cardiac cause of syncope?
  • What is your workup and management of this patient?
what is syncope
What is syncope?
  • Sudden, transient loss of consciousness
  • Rapid and complete recovery
  • May have minor myoclonic jerks or muscle twitching
  • No postictal state
how is a generalized seizure different than a syncopal episode
How is a generalized seizure different than a syncopal episode?
  • Aura (parasthesia, noises, light, vertigo)
  • Tonic-clonic movements and loss of consciousness
  • Post ictal confusion for minutes-hours
  • Tongue biting
  • Incontinence bowel or bladder

Prodrome often occurs

Feeling faint, hot, lightheaded, weak, sweaty

Brief loss of consciousness

seconds to 1-2 minutes

Rapid and complete recovery

Speaking normally within 1 minute

No post event confusion

what are the common causes of syncope mcc
What are the common causes of syncope? (MCC)
  • Cardiovascular (80%)
    • Cardiac arrhythmia (20%)
    • Decreased cardiac output –MI, Ao. Stenosis
    • Reflex/underfill (60%) (vasovagal, orthostatic)
  • Cerebrovascular (15%)
  • Other
    • metabolic
    • psychiatric
cardiovascular causes of syncope
Cardiovascular Causes of Syncope
  • Cardiac arrhythmia (20%)
    • Tachy or bradycardia
    • Carotid sinus syndrome
  • Decreased cardiac output
    • Inflow obstruction (to venous return) ex. PE
    • Squeeze: Myocardial ischemia (decreased contractility)
    • Outflow obstruction (Aortic stenosis, hypertrophic cardiomyopathy
cardiovascular causes of syncope1
Cardiovascular Causes of Syncope
  • Reflex/Underfill (60% of syncope)
    • Vasovagal (common faint)
    • orthostatic/postural ex. Blood loss
    • Situational (micturition, cough, defecation)
Cerebrovascular Causes (15%)
    • TIA
    • vertibral basilar insufficiency
    • high ICP
  • Metabolic : hypoxia, low BS, drugs, alcohol
  • Psychiatric: hyperventilation, panic
what is your initial approach with your patient with syncope
What is your initial approach with your patient with syncope?
  • Check ABC,s,
  • 5 vitals -postural
  • monitor, IV, ECG, blood tests
  • Bolus fluids if hypotensive 250-1000cc NS
  • glucosan
  • give thiamine if giving glucose
  • consider naloxone if patient not fully awake
  • history and physical
  • what happened (witnesses important)
  • what were you doing (ex. urination, standing up quickly etc.)
  • prodrome (hot, sweaty, vomiting)
  • any tonic-clonic activity
  • postural or neck turning
  • recovery – long or short
    • any confusion
review of systems
Review of Systems
  • volume status (eating, diarrhea, exercise)
  • recent blood loss
  • chest pain, palpitations, SOB,
  • any focal neurologic symptoms
  • pregnancy
  • previous history of syncope
  • ex. occasional episodes over the years vs several episodes recently (more sinister)
  • cardiac disease or medications
  • bleeding disorders or PUD
  • diabetes
  • medications ex. antihypertensives often cause orthostatic syncope
physical exam
Physical Exam
  • ABC
  • Orthostatic Vitals
  • HEENT: trauma, papilledema,
  • Resp/CVS: S3, AS murmur,
  • Abd: aorta, pulses, peritoneal, blood PR
  • Pelvic: bleeding, tenderness
  • Neurologic: focal findings
lab investigations
Lab Investigations
  • CBC
  • Type and xmatch
    • If suspect acute blood loss AAA, ectopic, GI bleed
  • Lytes, BS, BUN, Cr
  • D dimer
  • Pregnancy Test
  • ECG
  • CT Head if suspect cerebrovascular cause
  • Holter
  • EEG
vasovagal faint
Vasovagal Faint
  • Common (60% all syncope)
  • Increased parasympathetic tone
  • Bradycardia, hypotension
vasovagal faint predisposing factors
Vasovagal Faint -Predisposing Factors
  • Fatigue
  • Hunger
  • Alcohol
  • Heat
  • Strong smells
  • Noxious stimuli
  • Medical conditions anemia, dehydration
  • Valsalva (trumpet player)
vasovagal faint symptoms and signs
Vasovagal Faint Symptoms and signs
  • Warm, sweaty
  • Weak
  • Nausea
  • Confused
  • Unprotected fall
  • Eye rolling, myoclonic jerks,
  • Resolves in 1-2 min
  • Rarely tongue biting or incontinence
  • Not confused afterward
cardiac syncope
Cardiac Syncope
  • 20% all syncope
  • Serious prognosis
  • Exertional syncope
    • Outflow obstruction AS, IHSS
  • Ischemia/MI
  • Conduction disorders
  • dysrhythmias
  • Decrease in systolic BP by 20-30 or increase in pulse by 20-30 on standing
  • Supine
  • Meds -antihypertensives
  • Blood loss, dehydration
syncope when to admit
Syncope-When to Admit
  • Uncertain diagnosis
  • Elderly (more likely cardiac)
  • Suspected cardiac etiology
  • Abrupt onset with no prodrome (typical for dysrhythmia)
  • Unstable vitals
  • Blood loss
Our 73 y.o. man who collapsed in the bathroom and had a 30 second episode of unresponsiveness at 0430.

In the ED, he had another brief syncopal episode, following by sinus tachycardia

What is his problem?

What would you do?

Our 73 y.o. man who collapsed in the bathroom and had a 30 second episode of unresponsiveness at 0430.
  • Sick sinus syndrome: need pacer
an 80 y o man complains of recurrent syncope what is his diagnosis and treatment1
An 80 y.o. man complains of recurrent syncopeWhat is his diagnosis and treatment?
  • Third degree Heart Block
treatment of torsades
Treatment of Torsades
  • Correct electrolytes
  • Magnesium 2 gm over 20 min
  • Isoproterenol 2-20 mcg/min
  • Overdrive pacing
cardiac pacing when is it required
Cardiac Pacing When is it required?
  • 3rd degree (complete HB)
  • 2nd degree type ll
  • Sick sinus syndrome
  • Symptomatic bi or trifasicular blocks
    • Ex. RBBB + LAH + 1st degree HB
  • Symptomatic bradycardia
fitness to drive
Fitness to Drive
  • CPSO: > 16 yrs old
    • Suffering from a condition that may make it dangerous to operate a motor vehicle
  • Single episode of syncope that is easily explained ie. Simple faint dosen’t need reporting
  • Recurrent episodes or suspected cardiac cause
    • needs to be reported and the patient shouldn’t drive til a cause is determined and treated.


mcc objectives
MCC Objectives
  • Definition and Causes of coma
  • Clinical Assessment
    • Know how to examine a patient in a coma
    • Assessment tools (GCS)
  • Critical Investigations: appropriate lab and imaging
  • Management plan
    • Who needs immediate treatment; úrgent and emergent
    • Who needs specialized treatment
  • Management of Incompetent Patients-proxy decision-making
what is coma
What is Coma?
  • MCC Defintion:
  • state of pathologic unconsciousness (unarousable)
an 80 y o man is comatose 2 weeks after falling down stairs why is this patient comatose
An 80 y.o. man is comatose 2 weeks after falling down stairs? Why is this patient comatose?

Can be induced by structural damage or chemical depression

1) reticular activating system in brainstem, midbrain, or diencephalon (thalamic area)

    • Ex. Pressure from a mass
    • Toxins

2) Bilateral cerebral cortices

  • Ex. Toxins, hypoxia, hypoglycemia
causes of coma
Causes of Coma
  • Structural
    • Bleed, CVA, CNS infection,
  • Metabolic (medical)
    • A,E,I, O, U, TIPS
a 45 y o street person is brought in to the ed in a coma what are the causes
A 45 y.o. ‘street’ person is brought in to the ED in a coma. What are the causes?
  • A - alcohol, anoxia
  • E – epilepsy, electrolytes (Na, Ca, Mg), encephalopathy (hepatic)
  • I - insulin (diabetes)
  • O - overdose
  • U - uremia, underdose (B12, thiamine)
  • T- trauma, toxins, temperature, thyroid
  • I - infection
  • P - psychiatric
  • S - stroke (cardiovascular)
what is your initial approach with this comatose patient
What is your initial approach with this comatose patient?
  • A-airway protection (and c spine)
  • B-breathing O2 sat
  • C-5 vitals (pulse, BP, temp)
  • D-dextrose Glucoscan
  • Thiamine (if giving glucose)
  • Naloxone (should have small pupils)
  • IV, ECG monitor, foley, labs
  • Hx, Px
  • Determine level of consciousness
why thiamine if giving a bolus of glucose
Why Thiamine if giving a bolus of glucose

Precipitate Wernicke’s encephalopathy

Cranial nerve palsy - ocular



level of consciousness
Level of Consciousness
  • AVPU
    • Awake, verbal, pain , unresponsive
  • Glasgow Coma Scale

Best Eye Response. (4)

  • No eye opening.
  • Eye opening to pain.
  • Eye opening to verbal command.
  • Eyes open spontaneously.

Best Motor Response. (6)8 or less = coma

  • No motor response.
  • Extension to pain.
  • Flexion to pain.
  • Withdrawal from pain.
  • Localising pain.
  • Obeys Commands

Best Verbal Response. (5)

  • No verbal response
  • Incomprehensible sounds.
  • Inappropriate words.
  • Confused
  • Orientated
  • What happened?
  • Symptoms: depression, Headache
  • Gradual or sudden LOC
  • Sudden = intracranial hemorrhage
  • Gradual more likely metabolic, could be subdural
  • PMH: diabetes, thyroid, hypertension, substance abuse, alcohol
  • Meds,
physical exam1
Physical Exam
  • Goal: Try and determine if a structural lesion is present, or a metabolic cause.

How do structural lesions present differently than metabolic causes of coma?

physical exam2
Physical Exam
  • Structural lesions:
    • Often have focal findings, abnormal pupils, evidence of increased ICP
  • Metabolic causes:
    • No focal findings, pupils equal mid or small, no evidence of increased ICP
signs and symptoms of increased icp
Signs and Symptoms of Increased ICP
  • Headache, N, V,
  • Decreased LOC
  • Abnormal posturing
  • Abnormal respiratory pattern
  • Abnormal cranial nerve findings
  • Cushing Triad: late sign of high ICP
    • high BP, bradycardia, and low RR = high ICP
physical exam3
Physical Exam
  • Vitals
  • BP > 120 diastolic may cause encephalopathy
  • Hypotension uncommon with intracranial pathology
  • Temperature
    • Infection, CNS or otherwise
    • Neuroleptic malignant syndrome
      • antipsychotics, dopaminergic (levadopa) , or anti-dopamine (metoclopramide)
      • Altered mental status, muscle rigidity, and fever
  • Cheyne stokes
    • Fast alternating with slow breathing
      • Brain lesions, acidosis
  • Apneustic
    • Pauses in inspiration
      • Pons lesions, CNS infection, hypoxia
physical exam4
Physical Exam
  • HEENT:
    • Battle’s sign, hemotympanum.
    • Breath odour
      • Ex. Acetone = DKA
  • Metabolic:
    • pupils usually react
  • Structural:
    • may be unilateral dilatation Why?
      • Uncal herniation presses on CN 111,
      • Lose Parasympathetic tone
      • Unapposed sympathetic stimulation
  • 10% normal people have 1-2 mm difference
  • Fixed dilated pupils ominous
      • Dead, central herniation, hypoxic injury
  • Small pinpoint pupils
    • Lesion in pons (ischemic or bleed
    • Opiate OD
physical exam5
Physical Exam
  • Corneal Reflex
    • Sensory CN 5, and Blink is CN 7
extraocular movements
Extraocular Movements
  • Helps determine brainstem function in coma
  • Doll’s eyes
    • Eyes move in opposite direction to head movement
    • indicates functioning brainstem
oculocephalic reflex ensure c spine cleared
Oculocephalic ReflexEnsure C spine cleared
  • Awake person:
    • eyes look forward, some nystagmus
  • Comatose patient with brainstem function: Eyes deviate completely in opposite direction to head movement
  • Comatose Patient with no brainstem function
    • Eyes follow head movement
oculovestibular reflex cold calorics
Oculovestibular ReflexCold Calorics
  • Check eardrum
  • 50 cc iced saline
  • Awake person:
    • COWS
    • Nytagmus away from cold
    • Driving a car, cerebral cortex keeps you on the road
oculovestibular reflex cold calorics1
Oculovestibular ReflexCold Calorics
  • Comatose patient, intact brainstem
    • Eyes deviate to cold side
    • Hey who’s putting ice in my ear
  • Comatose patient, nonfunctioning brainstem
    • No reaction
physical exam cont
Physical Exam cont.
  • Disc
  • Nuchal rigidity
  • Resp/CVS/Abd/Extrem
  • Neuro:

level of consciousness, CN, Motor, Sensory, DTR

motor exam
Motor Exam
  • Is there asymmetry in response to pain
  • Evidence for seizures?
  • Withdrawing: nearly awake pt
  • Decorticate:
    • Abnormal flexion response. Flexes elbow, wrist, and adducts shoulder
    • Cerebral cortex injury
motor exam1
Motor Exam
  • Decerebrate posture
    • Extends elbow with internal rotation
    • Lesions or metabolic effect in midbrain
  • Flaccidity
    • Ominous sign
    • Toxin/OD
Labs ?
  • CBC,
  • Lytes, Bun Cr, BS
  • LFT, Ca, Mg,
  • ABG
  • Alcohol, Osmolality
  • Tox screen
  • CO level
diagnostic tests imaging
Diagnostic Tests/Imaging
  • CXR
  • CT Head
  • LP
  • ECG
  • EEG
a 25 y o woman presents in a coma pupils pinpoint rr 8 no focal findings what will you do
A 25 y.o. woman presents in a coma. Pupils pinpoint. RR 8. No focal findings?What will you do?
  • ABC’s, vitals
  • BS
  • Naloxone 0.4-2 mg IV
  • What if she is chronically taking narcotics?
a 30 y o man hit on the head comatose with a unilateral fixed dilated pupil what would you do
A 30 y.o. man, hit on the head, comatose with a unilateral fixed dilated pupil?What would you do?
  • Intubate, pC02 to 30 mmHg
  • Mannitol .5 gm/kg
  • CT Head
  • Stat Neurosurgery consult
summary coma
Summary COMA
  • ABC, Vitals, O2, CO2, BS, Naloxone
  • Metabolic vs Structural
  • Key to Exam
    • Respiration
    • Pupils
    • EOM
    • Motor response
competence capable
Competence / Capable
  • Understands medical issue
  • Understands treatment proposed
  • Understands consequences of accepting or refusing treatment
hypotension shock mcc objectives
Hypotension Shock – MCC Objectives
  • Causes
  • History
  • Examine
  • Diagnose: interpret symptoms and signs
  • Labs
  • Management strategy
    • Restore tissue perfusion
    • Specific therapy for each cause
what is shock
What Is Shock
  • Tissue hypoperfusion or tissue hypoxia
  • Catecholamine surge
  • Vasoconstriction, increased CO
  • Renin-angiotensin, vasopressin
    • Salt and water retention
  • If persists
    • Lactic acidois, decreased CO and vasodilation
    • Cell membrane ion dysfunction,
    • cell edema
    • Leakage of cellular contents
    • Cell and organ death
shock what are the causes
Shock What are the causes?






Obstructive Shock
    • PE, tamponade, tension pneumothorax
  • Cardiac
    • Pump failure: MI, ruptured cordae or septum
      • Contutsion, aortic value dysfunction
    • Dysrhythmia
    • Blood Loss
      • Trauma, AAA, aneurysm, GI bleed, ectopic
    • Dehydration
      • Gastro, DKA, Burns
  • Distributive
    • Sepsis –most common
    • adrenal, neurogenic, anaphylactic
    • Toxins (cyanide), CO, acidosis
initial management
Initial Management
  • ABC’s
  • Vitals
  • MAP = DBP + 1/3 PP (SBP-DBP)
    • MAP <70 = shock (inadequate perfusion)
  • IV How much?
    • Fill the patient up
      • Two, 16 ga, 500-1000cc bolus
      • Cardiac shock: bolus 250 cc at a time
hx and px
Hx and Px
  • Ask questions and examine carefully to rule in or out all of the major causes of shock
  • ABC approach
  • Head to Toe Survey
  • BS
  • CBC, lytes, liver/renal function
  • Lipase, fibrinogen, fibrin split products,
  • Cardiac enzymes, ABG, ECG, urine,
  • Tox screen
  • Stool OB
a 75 y o comes in confused x 2 days lethargic
A 75 y.o. comes in confused x 2 days, lethargic
  • BP 80/50 P. 130 T 38 RR 25 02 85%
  • What is his diagnosis?
  • What would you do?
septic shock
Septic Shock
  • Fluids: normal saline 1-2 litres
  • Oxygen
  • Treat the infection:
    • Antibiotics: broad spectrum
    • 3rd generation cephalosporins
    • Pip-tazo
  • BP support: inotropes: dopamine
A 39 y.o. man arrives in the ED having been stung by a bee 30 minutes ago. He has hives, facial and tongue swelling and is dyspneic.
  • What will you do?
  • BP 70/50 P. 140
  • 100 % oxygen
  • bolus 1-2 litres normal saline
  • epinephrine 0.3 mg IM q5min
      • or 5-15 microgm/min IV with shock
  • benadryl 50 mg IV
  • ranitidine 50 mg IV
  • solumedrol 125 mg IV
  • Glucagon 1mg IV if on beta blockers
cardiac arrest mcc objectives
Cardiac Arrest – MCC Objectives
  • Causes
    • Cardiac and noncardiac
  • Investigations
  • Management plan-CPR and ACLS protocols
  • Communicate
    • DNR
    • Death
    • Organ donation
    • Autopsy request
cardiac arrest causes
Cardiac Arrest - Causes
  • Cardiac
    • Coronary artery
    • Conduction
      • Metabolic: hypo Ca, Mg, K, anorexia
      • Brady or tachydysrhythmia
    • Myocardium
      • Hereditary: cardiomyopathy
      • Acquired: LVH, Valve disease, myocarditis
cardiac arrest causes1
Cardiac Arrest - Causes
  • Non Cardiac
    • Tamponade
    • PE
    • Tension
    • Trauma
sudden cardiac arrest
Sudden Cardiac Arrest
  • electrical accident due to ischemia or reperfusion
  • 80% ventricular fibrillation or

ventricular tachycardia

  • 20 % asystole

pulseless electrical activity

mechanism of fibrillation
Mechanism of Fibrillation
  • ischemia: slows conduction
  • adjacent myocardium in various phases of excitation and recovery
  • multiple depolarizing reentrant wave fronts
cardiac arrest
Cardiac Arrest
  • What are the key actions that are required to improve survival from cardiac arrest?
major changes of bls
Major Changes of BLS
  • Change in CPR sequence to :
    • C-A-B rather than A-B-C...
  • Begin with chest compressions !!!
major changes of bls1
Major Changes of BLS
  • Trained Layperson or Health Care Provider
    • 30 compressions, 2 breaths
  • Untrained layperson
    • Compression only CPR acceptable
    • ‘Hands Only’ CPR
major changes of bls2
Major Changes of BLS
  • Elimination of : “Look, Listen & Feel” for breathing...
      • …except for hypoxic arrest
  • Pulse check for Health Care Providers < 10 sec.
high quality c p r
High Quality C.P.R.
  • Compression : Ventilation ratio (30 : 2)
    • Until advanced airway
  • Minimize interruptions in CPR
  • Push Hard & Fast : 2 inches/ 100/ min.
  • Full chest recoil-lift hands off chest
  • Change compressors q2min
airway management
Airway Management
  • BVM (Bag-Valve-Mask)
    • Avoid hyperventilation!
    • 8 – 10 breaths / min. interposed with CPR
  • Secure Airway & Confirm Placement
    • No need to pause compressions!
      • Advanced airway: LMA, ETT
    • ETCO2 monitoring !
airway adjuncts
Airway & Adjuncts
  • Role of cricoid pressureduring cardiacarrest has not been studied.
  • Routine use of cricoid pressurein cardiac arrest is not recommended.
what are the only things that should interrupt cpr
What are the only things that should interrupt CPR?
  • Rhythm and pulse check
  • Ventilation (if advanced airway not present)
  • Advanced airway and intubation
  • Defibrillation

The crash cart arrives, you grab the paddles and have a quick-look

  • Is this
  • Normal sinus rhythm
  • Ventricular tachycardia
  • Ventricular fibrillation
  • Can I call a friend?

Would you:

  • Do 2 minutes of CPR then defibrillate
  • Defibrillate immediately
  • What if the patient had an unwitnessed arrest?
new cpr guidelines
New CPR Guidelines
  • Even with unwitnessed arrest….
  • Once V fib is recognized…shock ASAP
shock protocol
Shock Protocol
  • Shorten interval between compressions and shocking
    • improves shock success.
  • After shock delivery, resume CPR immediately
    • Don’t delay chest compressions for rhythm or pulse check
no change in recommendations
No Change in Recommendations
  • 1 shock then resume CPR
if you can t get an iv what other route can you give drugs
If you can’t get an IV, what other route can you give drugs?
  • Intraosseus
  • Endotrachael: (not a good route)
cardiac arrest medications no significant change in new guidelines
Cardiac Arrest MedicationsNo Significant Change in New Guidelines
  • Vasopressors
    • Epinephrine
      • 1 mg q3-5 min
    • Vasopressin
      • 40 units
      • May replace 1st or 2nd dose of epinephrine
cardiac arrest medications no significant change in new guidelines1
Cardiac Arrest MedicationsNo Significant Change in New Guidelines
  • Antiarrythmics
      • Don’t revert v fib.
      • Work by preventing V.Fib,
    • Amiodarone –
    • Procainamide
    • Lidocaine
    • Magnesium Sulfate
  • First line antidysrhymthmic
  • 300 mg IV bolus
  • May give 2nd dose: 150 mg
  • 1.5 mg/kg
  • Repeat x 1 prn.
The paramedics brings in a 56 y.o. man who arrested at home, was successfully defibrillated but remains comatose and intubated. BP. 100/70, P. 75 NSR
  • What other treatment options are available to you to increase survival?
therapeutic hypothermia for cardiac arrest
Therapeutic Hypothermia for Cardiac Arrest
  • Cool to 32-34°C x 24 hrs
  • Criteria:
    • adult patient prehospital cardiac (v.fib) arrest .
    • Spontaneous circulation BP > 90
    • Patient remains comatose and intubated
a 69 y o patient you are assessing for chest pain suddenly complains of palpitations
A 69 y.o. patient you are assessing for chest pain suddenly complains of palpitations
  • Is this
  • Normal sinus rhythm
  • Ventricular tachycardia
  • Supraventricular tachycardia
  • I don’t know but it looks bad
a 69 y o patient you are assessing for chest pain suddenly complains of palpitations1
A 69 y.o. patient you are assessing for chest pain suddenly complains of palpitations
  • Is this
  • Normal sinus rhythm
  • Ventricular tachycardia
  • Supraventricular tachycardia
  • I don’t know but it looks bad
What do you do next?

Determine if patient stable or unstable!

BP 110/60, no SOB, no chest pain

A) Give lidocaine 100 mg

B) give amiodarone 150 mg IV

C) sedate and cardiovert

D) Adenosine 6 mg IV

  • recommendedas a safe and potentially effectivetherapy in wide-complex tachycardia
  • Poor evidence
  • Level 11b: Observational retrospective studies
    • Critical Care Medicine – Marill, KA Sept 2009
which medications are useful for terminating monomorphic vt
Which medications are useful for terminating monomorphic VT
  • Lidocaine: 6 studies (8-30% effective)
  • Procainamide: few studies
    • 30% effective
  • Amiodarone: small case reports only
      • 30%
amiodarone in v tach
Amiodarone in V. Tach
  • 150 mg over 10 min
  • may repeat up to 5-7mg/kg
  • infusion: 1 mg/min for 1st 6 hours
          • then 0.5 mg/min
lidocaine in v tach
Lidocaine in V. Tach
  • 1.5 mg/kg bolus
  • 2nd and 3rd dose: 0.75 mg/kg q 5 min
  • Total maximum: 3 mg/kg
ventricular tachycardia
Ventricular Tachycardia
  • Do not give multiple antidysrhythmics if one has failed (pro-arrhythmic effects)
  • pick one antidysrhythmic, if it fails, go to electrical cardioversion.
ventricular tachycardia summary
Ventricular Tachycardia-Summary
  • If stable: can try drugs but cardioversion best choice
  • If unstable: cardiovert (synchronized)
  • If pulseless: defibrillate
  • Drugs rarely effective
an 80 y o patient admitted for pneumonia is found unresponsive by the medical student
An 80 y.o. patient admitted for pneumonia is found unresponsive by the medical student
  • What is your management
  • This is his rhythm on the monitor!!


CPR - Intubate - IV access

Confirmation in 2 leads


Possible causes


Hyperkalemia Drug overdoses


Epinephrine 1 mg IV q 3 - 5 min

(consider 1 dose Vasopressin 40 IU IV may replace 1st or 2nd dose epinephrine)

Considertermination of efforts

Atropine no longer recommended

Witnessed Arrest ?

ACLS futile?


A 65 y.o. man admitted to the CCU with chest pain is found unresponsive by the medical student. He has no pulse. He has the following rhythm

  • Treatment:
  • Find and treat cause
  • (Is there a shockable rhythm?)
  • Epinephrine 1 mg IV
  • (no longer atropine)
  • Consider causes:
    • 5 H’s :
    • hypovolemia, hypoxia, H ion, hyper/hypo K,
    • 5 T’s:
    • tamponade, tension pneumo, thrombosis-coronary or pulmonary, tablets OD

A 49 y.o. patient arrives in the ED complaining of palpitations for 1 hour.

What is this?

A) Atrial fibrillation

B) Atrial flutter

C) Ventricular tachycardia

D) A-V nodal re-entrant tachycardia

E) Sinus tachycardia

What will you do?

a 75 year old woman complains of dizziness
A 75 year old woman complains of dizziness.


B) Second degree HB type 1

C) Second degree HB type 2

D) Third degree HB

What are the treatment options if:1) her BP is 120/80 and she looks well2) her pulse was 45, BP 70/30 and she looks ill

second degree hb type ll
Second degree HB type ll
  • Dysfunctional His Purkinje system

can lead to complete heart block

  • If stable, send to monitored bed, and arrange permanent transvenous pacer
  • If unstable: external pacing, or dopamine or epinephrine infusion.

A 70 yo woman complains of dizziness x 3 days

What is this rhythm?


B) Second degree HB type 1

C) Second degree HB type 2

D) Third degree HB


A 70 yo woman complains of dizziness x 3 days

What is this rhythm?


B) Second degree HB type 1

C) Second degree HB type 2

D) Third degree HB

bradycardia when to treat
BradycardiaWhen to Treat ?
  • Symptomatic: chest pain, SOB, hypotension
  • Therapy:
    • atropine 0.5-1 mg (max total 3 mg)
    • transcutaneous pacemaker OR
    • dopamine 5-20 microgm/kg/min OR
    • epinephrine 2-10 microgm/min

Is this: A) Pericarditis

B) Benign Early Repolerization


A) Agree B) Disagree


Is this: A) Pericarditis

B) Benign Early Repolerization


A) Agree B) Disagree

myocardial infarction what can you do
Myocardial InfarctionWhat can you do?
  • MONA
    • ASA 160 mg chew
    • Oxygen
    • nitrates sublingual or IV
    • morphine 2-3 mg prn
myocardial infarction what can you do1
Myocardial InfarctionWhat can you do?
  • Antiplatelets: clopidogrel or ticagrelor
  • Heparin
  • Thrombolytics < 30 mins
  • Primary PTCA <90 mins
    • Percutaneous transluminal coronary angioplasty

An 80 year old man is being treated in hospital for pneumonia. He is found VSA at 0300. His rhythm shows asystole.How long are you required to perform CPR for?

when not to initiate cpr
When Not To Initiate CPR
  • CPR is inappropriate and ineffective for medical problems where death is neither sudden or unexpected
  • don’t offer CPR as an option to patients or families if it is not medically indicated
  • communicate openly
when to discontinue cpr
When to Discontinue CPR
  • Judgement that patient is unresuscitatable
  • Variables:
    • down time, rhythm, age, premorbid conditions
    • advance directives

You have just finished a 45 minute unsuccessful resuscitation attempt on a 42 y.o. man. His wife is anxiously waiting.How do you tell her that her husband has died?How do you make it less stressful on the survivors when a sudden unexpected death has occurred.

sudden unexpected death
Sudden Unexpected Death
  • Develop multidisciplinary approach
  • Develop intervention strategy
  • Contacting Survivors
    • Avoid disclosure on the phone
    • meet family at a specific site

CMAJ 1993 149(10) 1445-1451

sudden unexpected death1
Sudden Unexpected Death
  • Arrival of Survivors
    • met by RN, or Social Worker
    • updated regularly

Should the family be brought to the bedside

if the resuscitation attempt is ongoing ?

sudden unexpected death2
Sudden Unexpected Death
  • Notificiation of Death
    • obtain all information prior to meeting
    • quiet room, have RN also there
    • sit next or across from closest relative
    • explain in lay terms sequence of events
    • use the words dead or died
    • express condolences
    • answer questions now or later
sudden unexpected death3
Sudden Unexpected Death
  • Grief Response
    • private time
  • Viewing Deceased
    • encourage family
    • clean patient and remove equipment if possible
  • Conclusion
    • return valuables, address concerns
    • give family permission to leave