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2. Neurological / Spine related issues • Potential for irreversible neurologic damage • Neurologic emergencies • Stroke: ischemic, hemorrhagic • Subarachnoid hemorrhage • Spinal cord injury • Status epilepticus • Failure to perform an adequate neurologic examination Red Flags for Acute Low Back Pain HISTORY • Cancer • Unexplained weight loss • Immunosuppression • Prolonged steroid use • Intravenous drug use • Urinary tract infection • Pain increased or unrelieved by rest • Significant trauma related to age • Bladder or bowel incontinence • Urinary retention PHYSICAL EXAM • Saddle anesthesia • Loss of anal sphincter tone • Major motor weakness in lower extremities • Fever • Vertebral tenderness • Limited spinal range of motion • Neurologic findings persisting beyond one month 3. Cardiac and Stroke-related Issues • August 2000: 50y/o Filipino male presents to ED with nausea, HA, dizziness, double vision • He was sent home with painkillers, diagnosed with sinusitis by unlicensed PA without an adequate history or neuro exam • Returned to ED next day; diagnosed with CVA and had surgery to relieve cerebral edema • In a coma for 3 months & permanently disabled • Case went to trial and plaintiff was awarded $217 million jury award, largest in FL history Stroke Misdiagnosis • 3rd leading cause of death in U.S. • Risk factors similar to that of heart disease • Factors involved in misdiagnosis • Timeliness • Failure to do thorough H&P • Misreading of MRI / CT • Not giving TPA when indicated (within 3 to 4.5 hours of symptom onset) Cardiac Misdiagnosis • Heart disease leading cause of death in the U.S. with about 700,000 deaths annually (29% of all deaths) • PIAA Acute MI Study • Claims: 3rd most expensive and 4th most prevalent • Most common root cause: diagnostic error, especially ECG misinterpretation 4. Infection and Communicable Diseases 1. Recognize sepsis 2. Prescribe antibiotics wisely 3. Break transmission of communicable disease The Impact of – and Difficulty in Recognizing – Sepsis • 150K deaths annually based on death certificates, but higher based on admin claims • Present in ~10% of inpatients on admission, but contributes to up to half of all hospital deaths in US • Requires critical thinking – no confirmatory lab marker • Sepsis may be “overdiagnosed” through administrative data as a wastebasket term for anyone with inflammatory response • Early sepsis or even overt sepsis may present similarly to other systemic conditions CDC. MMWR 2016; 65(13): 342-45 Liu V et al. JAMA 2014;312(1):90-92 doi:10.1001/jama.2014.580 Sepsis: Old Definitions Had Issues • 2001 SIRS (markers of inflammation) was oversensitive, not specific • T>38, <36 • HR >90 • RR >20 or PaCO2 <32mm Hg • WBC >12K, <4K • Almost half of hospitalized patients had SIRS, or an inflammatory response; think about your sepsis alert • Severe sepsis, what we typically think of sepsis • Septic shock Am J respir Crit Care Med 2015; 192:958-964 3rd International Consensus Definition (February 2016) • Re-appraised latest understanding: life-threatening organ dysfunction caused by dysregulated host response to infection • Removed severe sepsis • Septic shock is “really, really, really bad” sepsis, i.e. high mortality (requires vasopressors MAP ≥65 mmHg and lactate >2 mmol/L, mortality >40%) • Better but not perfect JAMA 2016; 315:801-10 SOFA, and qSOFA • Objective measurements of organ dysfunction • Sequential organ failure assessment • best in ICU • ≥2 SOFA • Mortality ~10% • qSOFA • RR ≥22 • Altered mentation • Systolic BP <100 • Best in ED/ wards Sepsis Redefinition using SOFA PaO2/FiO2 (mmHg) SOFA score Bilirubin (mg/dl) [μmol/L] SOFA score >< 400 1 1.2–1.9 [> 20-32] 1 < 300 2 2.0–5.9 [33-101] 2 < 200 and mechanically ventilated 3 6.0–11.9 [102-204] 3 < 100 and mechanically ventilated 4 > 12.0 [> 204] 4 Glasgow Coma Scale SOFA score Platelets×103 /µl SOFA score 13–14 1 < 150 1 10–12 2 < 100 2 6–9 3 < 50 3 < 6 4 < 20 4 Mean Arterial Pressure OR administration of vasopressors required SOFA score Creatinine (mg/dl) [μmol/L] (or urine output) SOFA score MAP < 70 mm/Hg 1 1.2–1.9 [110-170] 1 dop <= 5 or dob (any dose) 2 2.0–3.4 [171-299] 2 dop > 5 OR epi <= 0.1 OR nor <= 0.1 3 3.5–4.9 [300-440] (or < 500 ml/d) 3 dop > 15 OR epi > 0.1 OR nor > 0.1 4 > 5.0 [> 440] (or < 200 ml/d) 4 Nonetheless, Sepsis Protocols Remains Valid • New definitions • Do not change the need to identify early and treat early • Do not affect the CMS measures • Early management (within 3 to 6 hours) • Stabilization of airway, breathing • Perfusion • hypotension with fluids • Lactate • Broad spectrum antimicrobials • Blood cultures first if possible • Guided by likely source and pathogens, if uncertain then vancomycin + broad gram negative • Concern about overuse of antibiotics? Not if critical thinking skills utilized Many URIs are Viral, Even in Inpatient Setting • Sinusitis • 90-98% viral • Abx if persistent >10d, severe >3-4d,