Emergency - Quality, Education and Safety

Teleconference

Dr Lisa Lee-Horn | Advanced Trainee | Emergency Care Institute

March 2019

Thanks for joining

House rules

Confidentiality

Respect

AGENDA

• “Dangerous Back Pain”

• Case reviews

• Underlying causes

Participation encouraged throughout

(But please turn off camera & mute mic when not talking)

Case 1 – Initial presentation

63yo woman presents with lower abdo pain

• 3rd presentation in 10 days

• 2 week history back pain

• Now has leg pain, bilateral leg weakness & difficulty with

urination

• Also c/o sweating and flushing in face

• Discharged last time after in/out IDC

Case 1 – cont

• Describes pain as mostly R-sided

• Now developed burning pain in both thighs

• Not relieved with simple analgesia or positioning

• Sleep disturbed by pain

Background:

• DM

• Smoking 40yrs

• Denies drugs or ETOH

Case 1 – cont

Vitals at Triage

• BP 173/103

• HR 96

• RR 20

• T 37.2

• Sats 99% RA

Thoughts?

• Differentials?

• What next?

• Red Flags?

Case 1 – cont

Assessment:

• Writhing in pain on gurney

• Lower and mid back tender on palpation, tender over R

paraspinal muscles

• Abdo: Suprapubic fullness, no other masses, not

peritonitic

• Neuro: Brisk reflexes LL, Prox leg weakness, Decreased

sensation in R leg, No DRE performed

Case 1 – cont

Initial Investigations

• Bloods: WC 28 (normal: 4 – 11)

• UA positive for leukocytes

• Lumbar XR: erosion of endplates L3-4

WHAT NOW?

• Treat pain then reassess

• Start antibiotics (IV Cephalosporin and Vancomycin)

• Likely impingement of spinal cord so needs definitive imaging

• MRI: demonstrated spinal epidural abscess

• Commenced on Ceftazidime and Vancomycin

Case 1 - cont

•What went well?

•What could have gone wrong?

•How can this help local

management?

DISCUSS

Triage

• 37yo woman

• Presents with right-sided lower back pain for the past 7 hours

• No improvement with simple analgesia

• No urinary symptoms

• Unable to mobilise

Case 2

Triage

• HR 89, regular.

• States pain 10/10

• Currently in private rehab for narcotic abuse, being stabilised on

suboxone

• 2/12 post-partum. Baby safe with father.

Case 2 - cont

Thoughts?

• Differentials?

• What next?

• Red Flags?

• Initially reviewed by JMO and given analgesia (indomethacin and

paracetamol)

• Neurological assessment NAD

• Regular simple analgesia charted

• Admitted to Short Stay overnight for discharge back to rehab in the

morning

• Reviewed in the morning

• Pt still in significant pain

Case 2 - cont

• Recently well, denies infective symptoms.

• Developed R buttock pain, radiating into R foot/toe yesterday.

• Did have mild R-sided sciatica during third trimester which resolved

after giving birth.

• Denies falls, precipitating trauma, bladder or bowel symptoms,

weight loss.

• Last injected heroin 10 days ago.

Case 2 – History Revisited

• A little drowsy from “a poor night’s sleep”

• Afebrile

• All obs within normal limits

• Has opened bowels and emptied bladder since being in ED

• Noted to being in significant discomfort whilst moving in bed

Case 2 - Examination

• Resp, CV and abdo examination NAD

• No midline bony tenderness or spine or sacrum

• Very tender over R paraspinal muscles at lumbar region

and over sacroiliac crest

Case 2 - Examination

Neurological:

• R Leg:

• Normal tone

• Reduced power with hip flexion secondary to pain

• No objective loss of sensation in leg

• Exacerbation of pain on straight leg raise

• Reflexes present and equal bilaterally

• Down-going Babinski bilaterally

Case 2 - Examination

• UA: NAD

• EUC all within normal limits

• WCC 18.1 / Hb 107 / Plt 311

• CRP 90

• Blood cultures pending

• Bhcg negative

WHAT NOW?

Case 2 - Investigations

• Lumbar and pelvic XR: NAD

• CT Lumbar arranged and pt admitted under

Rheumatology for lack/sciatic pain and concern for

epidural abscess/discitis (pending B/C and CT scan)

• IV antibiotics commenced pending results

Case 2 - Investigations

• MRI scan: signal abnormality with enhancement at the

right SIJ with abscess formation at both anterior and

posterior margins extending into the paraspinal and

iliopsoas musculature in keeping with a septic joint.

Associated pathological fracture of the R S1 sacral ala

region.

Case 2 -Outcome

• 2x Blood cultures (3 days apart) returned positive for

Staph aureus

• Admitted for 4 weeks of IV Flucloxacillin

• TOE: normal, no vegetations

• Repeat MRIs demonstrated resolution of collection.

• DC home for 8-weeks PO Flucloxacillin

Case 2 -Outcome

Epidural Abscess

• Suspect in those with fever & back pain

• Risk factors: immunocompromised (incl. DM, steroid use,

cirrhosis), alcoholism, IVDU, recent spinal

surgery/implementation

• Fever occurs in 50% of cases

• Only 10% present with classic triad of fever, back pain,

neurological deficit

Epidural Abscess

• Often missed on first visit as patient often has a few non-

specific symptoms

• 4 phases:

1. Initial non specific (malaise, vague back pain)

2. Early neurological symptoms

3. Paralysis, bladder dysfunction

4. Sepsis, death

Case 3 – Initial presentation

• 29yo man BIBA from home

• Sudden onset mid-thoracic back pain whilst showering

• Associated with intermittent SOB

• Cramp-like nature, spasmodic. Fluctuating but never

going away.

• Ambulance administered Methoxy and 10mg IV

Morphine

• Ambulated into ED, c/o mild thoracic discomfort

Thoughts?

• Differentials?

• What next?

• Red Flags?

Case 3 – Triage Obs

• RR 30

• Sats 99% RA

• HR 71 reg

• BP 174/94

Case 3 – PMHx

• SVT

• Marfan’s Syndrome

• Scoliosis

• Social: smoker

• Recreational drug use (PO only)

• Nil medications

• Possible allergy to suxamethonium

Case 3 – Further History

• Was working all day as a chef

• Whilst showering developed sudden onset thoracic back

pain

• Felt like a pulled muscle then spread to chest and under

ribs

• Developed dyspnoea and light-headedness

Case 3 – cont

• O/E

• Pt’s pain increasing and became diaphoretic and

distressed

• Urgent CT aortagram organised

Case 3 – cont

• Type A dissection with retrograde Type B dissection

involving L subclavian artery to the aortic bifurcation. L

false lumen supplies the L kidney and L common iliac

artery with partial extension in to the L subclavian artery.

• Initially treated with antihypertensives (labetalol and

clevidipine infusions).

• Open chest surgical repair (Bentalls + hemiarch) on day

3 of admission.

Aortic Dissection

Aortic Dissection

• Most common 60 – 80 yo (65% are male)

• Most occur in waking hours

• Predisposing risk factors

• HTN

• Genetic syndromes: Marfan syndrome, Ehlers-Danlos syndrome

• Bicuspid AV

• Previous aortic instrumentation

• Known AAA

Signs and Symptoms

• Pain

• Back-pain more common with Type B dissection

• Chest pain more common with Type A dissection

• Painless dissection (in DM, AA, previous CV surgery), present with syncope,

heart failure, stroke or neurological symptoms.

• Hypertension is present in 70% of Type B dissections but only in 25 to 35%

of type A dissections

• Heart murmur

• Focal neurological deficits (eg Horner’s syndrome, hoarse voice)

• Pulse deficit

CXR Findings

ADD-RS

• The Aortic Dissection Detection Risk Score (ADD-RS) is based on the

presence of one or more of the following:

• High-risk condition such as Marfan syndrome, family history of aortic

disease, known aortic valve disease, known thoracic aortic aneurysm, or

previous aortic manipulation, including cardiac surgery.

• Pain in the chest, back, or abdomen described as abrupt, of severe intensity,

or a ripping/tearing sensation.

• Physical examination findings of perfusion deficit, including pulse deficit,

systolic blood pressure difference, or focal neurologic deficit, or with aortic

diastolic murmur and hypotension/shock.

CLINICAL TOOLS AND GUIDELINES

E-QuESTs so far•Atypical Chest Pain - ACS

•Sepsis in the elderly

•Abdominal pain in the elderly - AAA & Ischaemic gut

•Scrotal emergencies

•Deadly headaches

•Paediatric deterioration

•Head injuries

•Opthalmological emergencies

Looking to next month, please…

•Share your cases

•Share your patient safety actions

•Spread the word with your colleagues

(or send me their email: Lisa.leehorn@health.nsw.gov.au)

What would you like to see / hear about?

Level 4, 67 Albert Avenue

Chatswood NSW 2067

PO Box 699

Chatswood NSW 2057

T + 61 2 9464 4666

F + 61 2 9464 4728

aci-info@health.nsw.gov.au

www.aci.health.nsw.gov.au

Many thanks!

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DATE 24 April 08:00 am

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