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9/18/2013
Disclosure of Commercial Relationships:
Trauma, Abdominal Pain,
Nausea/Vomiting
Matthew A. Wheatley, MD FACEP
Grady Memorial Hospital
Medical Director, Clinical Decision Unit
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Nature of Relationship Name of Commercial Entity
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Advisory Board
Consultant
Employee
Board Member
Shareholder
Speaker’s Bureau
Patents
Other Relationships
None
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Objectives
• List factors in favor of observation for
traumatic conditions
• Identify conditions for which observation is
beneficial
• Discuss role of imaging and observation in
patients with suspected appendicitis
• Discuss observation unit management of
patients with renal colic
Why observation?
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Trauma is common
Some conditions require time to rule in or rule out
Inpatient care for minor conditions is expensive
Observation is more cost-effective
Observation has been shown to be safe in certain
settings
Trauma
The Numbers
• Trauma is common
– 41.9 million injury-related visits to
EDs nationally
– 1/3 of total ED visits
• NHAMCS study
• 52% of trauma expenditures for
patients with minor injuries
• MacKenzie et al. J Trauma 1990
• Davis et al. J Trauma 2007
• Minimally-injured patients stay >
24 hours awaiting studies
• Cowell et al. J Trauma 1988.
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Safety of observation
Certain conditions require observation
• Initial physical exam is insensitive for diagnosing
pathology
– Hemoperitoneum
• 39% sensitive 90% specific
– Pneumothorax
– Perforated viscous
• Need for serial exams/studies
– Penetrating chest trauma
– Blunt/penetrating abd trauma
• Pts with flank wounds develop signs and symptoms requiring
laparotomy appear within 18 hours (94% within 6 hours).
– MacLeod et al. Am Surg. Jan 2007.
– Head injury
What can be observed?
• Closed head injury
• Chest trauma
– Blunt
– Penetrating – Stab wound
• Abdominal trauma
– Blunt
– Penetrating – Stab wound
• Anterior
• Flank or back
• Soft tissue/orthopedic injuries
• Pain control
• Henneman, et al.
– 984 with abd trauma
• 230 (23%) observed 12 hours
• 105 blunt trauma; 115 penetrating trauma
– 82% discharge
– No surgeries
– Reduction in costs and admissions demonstrated
• Ammons, et al. J. Emerg med 1996
– 150 pts with thoracic trauma
• 129 discharged
• No increased morbidity/mortality in admitted pts
• 6-8 hour obs
What shouldn’t be observed?
• Gun Shot wounds
– Thorax
– Abdomen
• Polytrauma
• Thoracoabdominal
injuries
• Trauma in pregnancy
• Unable to ambulate
Initial Work-up
• Blunt Trauma
– Initial physical exam insensitive in blunt trauma
– FAST has improved sensitivity (86%)
– Soyuncu et al. Injury. 2007.
– Negative scan does not rule out traumatic organ
injury
– Stengel, et al. Cochrane Database of Systematic Reviews.
2005
– CT study of choice for most centers
• Not 100% sensitive for bowel, mesenteric or
diaphragmatic injury
Initial work-up
• Penetrating Trauma
– Local wound exploration
• Discharge if no violation of peritoneum
• Observe if violation demonstrated or unsure
– US
• Murphy et al: 59% sensitive, 100% specific in detecting facial
wound
– CT
• Triple contrast CT in the case of flank or back stab wound
– DPL
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Abdominal Trauma – Goals of
observation
• To determine the patients with peritoneal
injury require laparotomy and which may be
discharged
• The Alternatives
– Discharge home
– Admit to inpatient service
– Non-selective laparotomy results in 30-40%
unnecessary surgery
– Arikan et al. J Trauma. 2005.
Thoracic trauma – Patient Selection
• Inclusion Criteria
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Normal initial studies (CXR, EKG, etc)
Normal vital signs
Alert
Low clinical suspicion of serious injury
• Exclusion Criteria
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Unstable
Uncooperative
Central chest stab wound
Concern for thoracolumbar injury
Duration of obs – penetrating trauma
• Pts may be managed as an outpt if 6 hr CXR is negative
– Kerr et al. Surg Gynecol Obstet. 1989
• Ordog et al. J trauma 1994
– Prospective study, 10,544 pts
– 4,106 pts with asymptomatic wounds, negative initial CXR
– NPV initial CXR 87.4%
– 519 pts (12.6%) had delayed injuries
• All diagnosed within 8 hours of obs
Obs unit management
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Serial examinations
Pain control
Pulse oximetry
CXR
EKG, Cardiac biomarkers
Other studies
– CT/Echo
3 hour rule-out?
• Seamon et al. J Trauma 2008
– 100 low-risk patients
– Negative initial CXR
– 2 pts developed ptx/htx at 0-3 hurs
– No pts developed ptx or hts 3-6 hrs
– Mean LOS 8.8 hrs
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CT vs CXR
• Magnotti et al. Am Surg. 2007
– 118 pts with initial negative xr
• Immediate non-contrast CT chest
• 6 hr xr if CT negative
– CT identified 6 ptx and 2 htx
• 2 pts required operative intervention
– No delayed findings found on XR if CT negative
– Mean obs time 8 hours
Other wound types
• Require more extensive ED eval
• Central Chest wound
– 24 hour obs recommended for asymptomatic patients
• Aaland et al. Am Surg. 1994.
• Thoraco-abdominal wound
Blunt Chest Trauma
• Myocardial contusion
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No gold standard for diagnosis
Difficult to estimate rate of delayed complications
Potential interventions
Serial enzymes
Echo
• TEE preferred due to no limitations from rib fractures
• Recommended for high risk patients
– Nuclear studies not predictive of complications
• Rib fractures
– Can be observed for pain control and pulmonary care
Minor head injury
What about delayed bleeding?
• Definition
– GCS 14-15
– LOC or amnesia to event
• Nagy et al. J trauma 1999
– 1170 minimal head injury pts
– 96.7% with normal CT
– No adverse outcomes in 23 hour obs for these pts
– Conclusions: CT for everyone, pts may go home
with negative CTs
• Single site case series
• 97 consecutive patients
• 24 hour obs and repeat CT scan
– 5 pts (6%) had delayed bleeding
• 3 requiring hospitalization, 1 craniotomy
• 2/5 had INR > 3.0
• Relative risk of delayed bleeding for INR > 3 was 14
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OU role in minor ICH?
• Nishijima et al. Ann Emerg Med May, 2013
• Multicenter retrospective cohort study
• 11,240 adult patients
– GCS 15, injury severity score < 16 (no major organ injury)
– OU used at 4 sites
• 55 patients total
– 847 of 888 patients (95%) admitted to ICU did not receive
critical intervention
– 3 of 524 (0.6%) admitted to floor, OU or discharged
required critical intiervention
– Conclusion: Possible over use of ICU for these patients.
• Retrospective cohort review
• 827 patients seen in ED 285 (34%) admitted to OU
– 98% had head CT
• Skull fractures 39%
• ICH 13%
– 13 patients (5%) required admission
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Continued IVF (n=5)
Venous Thrombosis (n=2)
Persistent CSF leakage (n=3)
Decreased LOC (n=1)
Pain management (n=1)
C-spine clearance (n=1)
– Median LOS 13 hours
Pediatric Emergency Care 2005
Take Home points
• Low acuity patients with blunt and penetrating
trauma can be safely observed
– Serial exam, US, H/H in ant abdominal wounds to
detect need for laparotomy
– 6-8 hours obs with 6 hour CXR for penetrating trauma
to thorax
– Central chest wounds require longer monitoring
• Consider a period of observation for patients with
closed head injury and persistent symptoms or on
anticoagulation.
Scope of the problem
• Most common ED complaint
Abdominal Pain,
Nausea/Vomiting
The Slippery Slope?
– 8% of visits
– McCaig. National Hosp Amb Med Care Survey: 1997
• 20-25% require admission
– Graff et al. Ann Emerg Med. 1991.
• 3% of discharged patients return to ED within 3
weeks
– Lukens et al. Ann Emerg Med. 1993.
• Over 40% have uncertain diagnosis
– Leads to more admissions, negative work-ups,
surgeries, etc
– Brewer et al. Am J surg 1976
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Make it about something
• Single
condition/problem
– Rule-in or rule out
disease
– Diagnostic study
• 70-80% chance of
discharge in 24 hours
• Admit if not
improved in 15-18
hours
Abdominal Pain – Inclusion criteria
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Stable VS
Non-surgical abdomen
Negative pregnancy test
Ancillary signs/sx – anorexia, N/V, fever,
elevated WBC
• Ruling in or out a specific condition
– Appendicitis
– Cholecystitis
Abdominal pain – exclusion criteria
• Hemodynamcially unstable
• Surgical abdomen
• Uncertain endpoints
Suspected Appendicitis
– Chronic pain
• Special patient populations
– Transplant
– Immunosuppressed
– Terminal illness
Appendicitis: Background
• Appendicitis is the most common surgical emergency
• Missed appendicitis is the 4th largest source of medical
malpractice (15% of payout)
• Surgeons need to balance missed appy with negative
surgery
Limitations of CT
In undifferentiated abdominal pain patients:
– CT sensitivity 92% specificity 85%
– PPV 75%, NPV 95%
– Overall accuracy 90%
– Alternative diagnosis 66% of negative patients
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Limitations of CT
Goals of observation
• Reduce unnecessary operation in patients
without appendicitis presenting with typical
symptoms
• Reduce delay in diagnosis/perforation risk in
patients with appendicitis presenting with
atypical symptoms
• CT use in the diagnosis of
appendicitis has increased from 12%
in 1998 to 86% in 2004
• In the ENTIRE modern CT era:
– No change in negative laparotomy
rate
– No change in perforation rate
– Indeterminate change in improper
discharge or complication rate
(although most papers argue for
reduced complication rate and
quicker disposition)
Observation: an old technique
• Serial examination is the best tool for minimizing
perforation and reducing delays in diagnosis
• Graff et al. Ann Emerg Med 1991
– Patients with appendicitis develop more signs and
symptoms during EDOU stay
– Used MANTRELS score
• Lewis et al. Arch Surg 1975.
• Increasing physical exams from qday to tid improved
normal appendix rate 15% to 1.9%
• White et al. Am Surg 1975
• Thompson et al. Am J surg 1986
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Performance of Observation
Prospective trial, single observer exams, hourly vs
88% of patients completed 12 hour obs without laparotomy
11.8% required surgery
No complications due to delay in surgery
No return visits for abd pain in discharged pts.
Observation: MANTRELS score
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Characteristic
M = Migration of pain to the RLQ
A = Anorexia or acetone in urine
N = Nausea and vomiting
T = Tenderness in RLQ
R = Rebound pain
E = Elevated temperature (100.4F or 38C)
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• L = Leukocytosis
(>10,500)
2
• S = Shift of WBC to the left (>75% neutrophils)
1
• Total
MANTRELS score
Score
1
1
1
2
1
10
• Low score (0-3) may benefit
from observation
• Moderate score (4-6) may benefit from
immediate imaging (15-32% pretest probability)
• High scores 7+ should have urgent surgical
consult
• Average scores:
– With appendicitis: 6.8, increasing during
observation
– Without appendicitis: 3.8, decreasing to 1.6 during
observation
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MANTRELS score
Abdominal Pain:
Renal Colic
Graff et al. Ann Emerg Med 1991
“Kidney Stones”
. . . or ureteral colic
• Effects 5-15% of population worldwide
– ~ 50% recurrence rate
• Economic impact
– Indirect cost and loss of productivity = $1.7 billion/yr
• U.S. ED visits
– 4.4% (5 million) for genito-urinary emergencies
Renal Colic – Criteria to consider:
Transfer Criteria
• Diagnosis of renal colic established – CT or
ultrasound
• Persistent pain or vomiting despite
medication
• Acceptable VS
Exclusion Criteria
• Unstable VS
• Associated fever, UTI, pyelonephritis, sepsis
• Single kidney or anatomic variant
Renal Colic – Criteria to consider:
Potential Intervention
• IV Hydration
• Parenteral narcotics, toradol
• Expulsive therapies – tamsulosin,
steroids, or calcium channel blockers
• Parenteral antiemetics
• Serial exams and vital signs
• Strain urine, stone analysis, U/A if not
yet don
• Randomized patients to
placebo or Tamsulosin
plus steroids.
• Found more rapid
expulsion rate with
treatment.
• Demonstrated that a
significant portion of
stones will pass with a
period of observation
e
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Renal Colic Outcomes
• Hostetler (Rush) - Kidney stones / UTI
– Discharge rate
= 72%
– LOS
= 13.8 hr
• Ross (WBH) – Renal Colic
– Discharge rate
– LOS
Take-Home Points
• Focused observation period with serial
physical exams helps to improve diagnostic
accuracy of appendicitis
– Fewer unnecessary operations
– Fewer return visits in discharged patients
= 80%
= 13.1 hr
• Observation with medical expulsive therapy
for patients with renal colic helps improve
symptoms and spontaneous passage.
Resources
• Observation Protocols
Questions
– http://www.obsprotocols.org/tiki-index.php
– Emory Observation Services Manual available on
iTunes book store (it’s free)
– ACEP website >> Clinical & Practice management>>
Resources >> Observation Medicine
• Graff’s Observation medicine text book
• Sample protocols
• Clinical policy statements
• Coding & Billing
– http://www.acep.org/Clinical---PracticeManagement/Observation---Physician-Coding/
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Bibliography
Bibliography (cont.)
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• Flum DR, Morris A, Koepsell T, Dellinger EP.
Has misdiagnosis of appendicitis decreased
over time? A population-based analysis.
JAMA. 2001 Oct 10;286(14):1748
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• Graff LG 4th, Robinson D. Abdominal pain and
emergency department evaluation. Emerg
Med Clin North Am. 2001 Feb;19(1):123-36.
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Graff L, Mahadevan M, Russell J. Observation Improves CT Scan Utilization in
Abdominal Pain Evaluation for Appendicitis
Graff L, Radford MJ, Werne C. Probability of appendicitis before and after
observation. Ann Emerg Med. 1991 May;20(5):503-7.
Graff L, Russell J, Seashore J, Tate J, Elwell A, Prete M, Werdmann M, Maag R,
Krivenko C, Radford M. False-negative and false-positive errors in abdominal pain
evaluation: failure to diagnose acute appendicitis and unnecessary surgery.Acad
Emerg Med. 2000 Nov;7(11):1244-55.
Lee CC, Golub R, Singer AJ, Cantu R Jr, Levinson H. Routine versus selective
abdominal computed tomography scan in the evaluation of right lower quadrant
pain: a randomized controlled trial. Acad Emerg Med. 2007 Feb;14(2):117-22.
Paulson EK, Kalady MF, Pappas TN. Clinical practice. Suspected appendicitis.N Engl
J Med. 2003 Jan 16;348(3):236-42.
Welch, RD. Management of the Traumatically injured patient in the Emergency
Department Observation Unit.
Thank You
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