Interven'ons You should stop Performing. Dr. Vu Kiet Tran, MD, MHSc, MBA Emergency Physician University of Toronto

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1 Interven'ons You should stop Performing Dr. Vu Kiet Tran, MD, MHSc, MBA Emergency Physician University of Toronto

2 Useless interven'ons in the ED! Postural vitals Rectal exam for appendici's Segmental motor exam Urinalysis for appendici's Hemocult for GIB Tox screen Ins/Exp CXR Plain abdo Xrays KUB for renal colics Lateral soo 'ssue XRays Nasal Xrays Sacral bone Xrays Trendelenburg posi'on Sterile gloves for suturing Cover sutured wounds Abscess packing Rou'ne Gravol with Morphine Betahis'ne for BPPV ABG for O2sat and gap Electrolytes for CP An'bio'cs for Bronchi's An'bio'cs for Rhinosinusi's An'bio'cs for OMA 2

3 Table of Content DRE to help rule- in Cauda Equina Blood alcohol levels Kayexalate for acute hyperkalemia Oral contrast for CT scanning 4

4 Objec'ves Cri'cally examine some tradi'onal clinical prac'ces in the ED Understand the ra'onal behind these tradi'ons Provide convincing arguments to abandon these prac'ces Encourage to change prac'ce based on evidence 3

6 Rectal exam in the assessment of back pain Necessary exam in the evalua'on of acute low back pain (especially to rule- out cauda equina)? Invasive Uncomfortable Awkward for both pa'ent and clinician

7 Back pain in the ED Most back pain is not the result of tumour infec'on major trauma Most back pain begins spontaneously. In a study of over 11,000 pa'ents, 2/3 rds of the subjects could not recall any cause for the pain. Hall et al. Clin J Pain 1998

Red Flags of back pain Sphincter disturbance: bowel or bladder History of cancer Unexplained weight loss Immunosuppression Intravenous drug use Recent onset of structural deformity Recent or on-

8 Red Flags of back pain Sphincter disturbance: bowel or bladder History of cancer Unexplained weight loss Immunosuppression Intravenous drug use Recent onset of structural deformity Recent or on- going infec'on Fever Night sweats Non- mechanical pacern of pain Constant pain Wide spread neurological signs or symptoms Dispropor'onate night pain Lack of treatment response Thoracic dominant pain Under 20 and over 55

9 Syndrome recogni'on The key to syndrome recogni'on is the history History takes precedence over physical examina'on. But the physical examina'on must support the history.

10 Urinary vs bowel dysfunc'on Urinary reten'on: 60% Urinary incon'nence: 55% Prognosis is becer with reten'on than with incon'nence Bowel dysfunc'on less common than urinary dysfunc'on (more urine than stool in a day) Am J Ortho. 2008; 37(11):

11 Cauda equina

12 Cauda equina Has ventral and dorsal roots Dorsal: afferent fibers (sensa'on) Ventral: efferent fibers (motor)

14 Compression of the cauda equina

15 Physical Examina'on 1. Nerve root irrita'on tests 1. Straight leg raise test 2. Nerve root conduc'on tests L4: Knee reflex L5: Great toe flexion hip abduc'on ankle dorsiflexion S1: Great toe flexion ankle reflex ankle plantar flexion

16 Physical examina'on 1. Upper motor test plantar response Clonus 2. Sensory tes'ng 3. Saddle sensa'on lower sacral nerve roots (2,3,4) test

17 Three ques'ons two tests to rule out the Red Flags Where is your pain the worst? Is your pain constant or intermicent? Has there been a change in your bowel or bladder func'on? Test upper motor func'on. Test lower sacral sensa'on.

18 Tone or no Tone? Overall correctness in iden'fying tone: 64% Overall correctness in iden'fying squeeze test: 100% Spine. Aug ; 40(15):

19 DRE for MRI Test accuracy (DRE) was 51% Diagnos'c odds ra'o was 1.42 No correla'on between clinical finding in an individual pa'ent and MRI diagnosis DRE cannot be used as a discriminator to ra'on urgent MRI Br J NeuroSurg. Apr 2013; 27(2):

20 Relevance of rectal exam Between Spinal clinic in Oxford 33 pa'ent needing urgent opera've interven'on for diagnosis of Cauda Equina Only 11 had reduced rectal one (33% sensi'vity) Only 2 of the 11 had stool incon'nence BMJ 2008; 337: a2718

21 Relevance of rectal exam 85% sensi'vity Most sensi've symptoms Saddle anesthesia Numb feeling around my bocom (100% sensi'vity) strange feeling when sirng (43% sensi'vity) altered sensa'on when wiping my bocom (36% sensi'vity) Abnormal urinary symptoms BMJ 2008; 337: a2718

22 Sensory tes'ng 75% have decreased peri- anal sensa'on Am J Ortho. 2008; 37(11):

23 Take Home Abnormal urinary symptoms Saddle anesthesia Abnormal Post- void residual (> 100ml) MRI Rectal exam adds licle addi'onal clinical value in decision- making

24 Case 1 Mr. VKT presents to your ED intoxicated He smells of alcohol and admits he drank too much at the UHN conference social night out He had a lot of alcohol Denies any drug use He is vomi'ng and slurring his speech BP 110/70 Heart rate 105 RR Temp 37.5 oral O2Sat 98% RA

25 Case 1 Mr. VKT presents to your ED intoxicated Ethanol: 10 What will you do for Mr. Tran?

26 Case 2 Mrs. SSJ presents to your ED intoxicated She smells of alcohol and admits she drank too much at the UHN conference social night out She had a lot of alcohol Denies any drug use She is vomi'ng and slurring her speech BP 140/90 Heart rate 98 RR 20 Temp 37.3 oral O2Sat 95% RA

27 Case 2 Mrs. SSJ presents to your ED intoxicated Ethanol: 50 What will you do for Mrs. SSJ?

28 Case 3 Mr. RR presents to your ED intoxicated This is his 15 th visit this month for same He smells of alcohol and admits he drank today in the park Denies any drug use He is vomi'ng and slurring his speech BP 130/86 Heart rate 89 RR 20 Temp 37.0 oral O2Sat 95% RA

29 Case 3 Mr. RR presents to your ED intoxicated Ethanol: 65 What will you do for Mr. RR?

30 Ques'on? How was the management of these 3 pa'ents different? What feature(s) help you differen'ate your management? What feature(s) did not help differen'ate your management?

31 Concerning recent trend Increased tes'ng of blood alcohol levels in single alcohol intoxicated pa'ents both at TWH and TGH Tradi'onally not performed Why? What changed?

32 Blood alcohol level Blood alcohol concentra-on Symptoms % (< 22mmol/L) Euphoria Mild coordina'on deficits Mild acen'on and cogni'on deficits Decreased acen'on Ataxia Impaired judgment Slurred speech Mood variability Lack of coordina'on Incoherent thoughts Confusion > 030% Stupor LOC Coma Respiratory depression and death

33 Signs and symptoms Vary widely depending on Gene'cs Type of alcohol Amount Rate of intake Frequency Pacern of alcohol use

34 U'lity of BAL Unnecessary in pa'ents with isolated ethanol intoxica'on Treat the pa'ent, not the alcohol level Does not advance your diagnosis Does not change your management (nor the aggressiveness with which you would manage the pa'ent) Does not change the prognosis

35 When is BAL useful? No obvious cause for the altered mental status Head injury Seizure NYD Psychosis NYD Comatosed pa'ent Unstable vital signs Mul'ple co- inges'ons in the intoxicated pa'ent During treatment of Methanol or Ethylene Glycol with Ethanol Altered acid- base status Medico- legal scenarios Annals Emerg Med March 1986; 15(3):

36 Take home For a single uncomplicated intoxicated (with alcohol) pa'ent, a blood alcohol level should not be performed as it does not change diagnosis, management, or prognosis

37 Hyperkaliemia 76yo male presents with weakness and lethargy BP 90/56, pulse 35, RR 16, temp 36.9 K + is

38 How would you treat this hyperkaliemia? A. Insulin and Dextrose B. Insulin, Dextrose, and Calcium C. Insulin, Dextrose, Calcium, and Furosemide D. Insulin, Dextrose, Calcium, Furosemide, and Beta 2- agonist E. Insulin, Dextrose, Calcium, Furosemide, Beta 2- agonist, and Kayexalate F. Insulin, Dextrose, Calcium, Furosemide, Beta 2- agonist, Kayexalate, and dialysis G. Insulin, Dextrose, Calcium, Furosemide, Beta 2- agonist, and dialysis 38

39 Kayexalate Sodium Polystyrene Sulfonate Resin and binds potassium Gets into the stool and eliminate the potassium from the body Decrease potassium in 4-6 hours Nurses hate it Pa'ent hate it 39

40 Kayexalate Based on 2 reports that were not studies NEJM 1961 Jan 19, 264: pa'ents No potassium diet Potassium fell by 0.5mEq/L on day 1 and 1mEq/L on day 2 NEJM 1961 Jan 19; 264: pa'ents Low- potassium diet Potassium level fell by 0.4mEq/L in the first 24 hours 40

41 Only study on Kayexalate 6 pa'ents with CRF Placebo vs Sodium polystyrene- sulfonate vs Phenolphtalein- docusate vs Phenolphtalein- docusate +resin vs sorbitol+resin Fecal excre'on of total potassium was less with sorbitol+resin None of the resin- cathar/c regimens caused a fall in serum potassium concentra/on No correla'on between fecal potassium and serum potassium levels 41 J Am Soc Nephrol 9: , 1998

42 What is the harm? The resin causes severe cons'pa'on Sorbitol was added to prevent cons'pa'on This combina'on can produce severe acute colonic necrosis Rare (incidence es'mated at %), but fatal Culprit is most likely the cathar'c (sorbitol) 42 Am J Kidney Dis. 1992; 20: Am J Surg Pathol. 1997; 21: 60-69

43 Acute colonic necrosis Kayexalate is implicated in the development of intes'nal necrosis, primarily mediated by the sorbitol component: South Med J May; 102 (5): Surgery 1987, 101 (3): Can J Gastroenterol Oct; 11 (7): Am J Surg Patho Jan 1997, 21 (1): Am J Kidney Dis July 1997, 30 (1):

44 Is Kayexalate safe? In 2009, FDA has put out a black box warning: The drug may cause acute colonic necrosis 44

45 Is Kayexalate safe and effec've? Clinicians must weigh uncontrolled studies showing benefit against uncontrolled studies showing harm It would be wise to exhaust other alterna'ves for managing hyperkaliemia before turning to these largely unproven and poten'ally harmful therapies 45 J Am Soc Npehrol 21: , 2010

48 Oral contrast for CT scanning

50 Problem Administra'on of oral contrast requires an extra minutes Can be difficult for nauseated pa'ents

51 Protocol Oral contrast needs to be administered minutes prior to the CT scan Some need to wait even longer 3h for the contrast to reach small and large bowel

52 CT abdo for appendici's in Adults Without contrast/with contrast Sensi'vity 95% vs 92% Specificity 97% vs 94% PPV 97% vs 89% NPV 96% vs 96% Accuracy 96% vs 92% Am J Surgery 19 (205);

53 CT abdo for appendici's in Adults Sensi'vity 92.7% (95% CI, 89.5%- 95%) Specificity 96.1% (95% CI, %) Posi've LR 24 Nega've LR 0.08 Ann Emerg Med. 2010; 55: 51-59

54 Low BMI Decreasing need for oral contrast in ED abdopelvic CT as pa'ent s BMI > 25 Western J Emerg Med. 2013, 5;

55 Impact on ED LOS With IV/PO contrast With IV contrast Total exams Male 41.7% 45.7% Female 58.3% 54.3% Study indica'ons Appendici's Small bowel obstruc'on Diver'culi's Perfora'on 59.2% 20.9% 16.6% 3.3% 65.8% 19% 10.9% 4.3% Total ED LOS 6:39 (5:18-8:05) 4:35 (3:29-5:53) Time to OR 5:40 (4:28-6:50) 4:05 (2:53-5:17) Rescan within 2 weeks 19 (9%) 16 (8.7%) Western J Emerg Med. 2012; 13 (5);

56 No Oral Contrast Abdopelvic CT Examina'on (NOCAPE) Reduced order to complete TAT by 32min c/t IV and oral contrast CT Median order to final TAT was 2.9h in NOCAPE c/t 3.5h in the tradi'onal CT protocol 36 min (17%) reduc'on Overall, reduced ED LOS by 43min (8.8%) Recall and bounce- backs were 3.2% Emergency radiology, Dec 2014, vol 21 (6):

57 CT scan in children Adequate intra- abdominal fat (IAF) is propor'onal to age and weight Weight being the becer predictor of adequate IAF Protocols using IV alone to visualize the appendix can reasonable if age and weight are considered Acad Emerg Med Aug; 20(8);

58 Bocom line Oral contrast is unnecessary for most ED CT scans of the abdomen and pelvis Removing oral contrast administra'on from the CT scanning process can improve ED LOS Certain condi'ons may s'll benefit from oral contrast Fistula Perfora'on Low BMI (lack of retroperitoneal fat may make inflammatory changes difficult to iden'fy)

59 Bocom line Talk to your radiologist to discuss the case and the need for oral contrast Discuss which cases absolutely needs oral contrast

60 Summary DRE adds licle value to diagnosing Cauda Equina beyond the search for saddle anesthesia and abnormal voiding/bm Blood Ethanol level adds licle value to diagnosis, management and prognosis to the obvious alcohol intoxicated pa'ent

61 Summary Kayexalate can be poten'ally harmful and ineffec've against acute hyperkalemia. Many other more effec've op'ons exist. Oral contrast is unnecessary for most ED CT scans of the abdomen and pelvis

62 Table of Content DRE to help rule- in Cauda Equina Blood alcohol levels Kayexalate for acute hyperkalemia Oral contrast for CT scanning 4

63 In God [insert the name of your god] we trust. Everyone else must Bring Data bring data! 73

64 Thank you 74

HIGH LEVEL - Science

Learning Outcomes HIGH LEVEL - Science Describe the structure and function of the back and spine (8a) Outline the functional anatomy and physiology of the spinal cord and peripheral nerves (8a) Describe