Emergency Red Flags

Safety VS Accuracy

DR.MAGDY KHAMES ALY

CRITICAL CARE MEDICINE
ZMH AL BATAYEH
 Objectives

 Learning about common cognitive errors in emergency

diagnosis .
 Identification of specific clinical situation in which
diagnostic errors are most likely to occur, commonly
known as “pitfalls”
 List the unique features and (atypical) presentations of
common emergency situation.
 Identify priorities for initial triage
 Teaching Points to be Addressed

 What is the usefulness of the clinical

warning criteria (red flags) ?

 How do we use the information from the

critical warning criteria?

 Is there any special group of patients?

 Definitions
 Cognitive errors: are simply ways that our mind
convinces us of something that isn't really true. These
inaccurate thoughts
For example, premature diagnostic closure, also
known as “anchoring” = the practice of locking onto an
early diagnosis, subsequently ignoring or failing to seek
further data that might disprove one’s initial impression.
The prevalence of this error has been reported to be as
high as 90%.
 Pitfalls: (eg. abdominal pain in the elderly).
Headache and facial pain
 Red flags
 Systemic upset
 Progressive pain, disability and distress
 Focal neurological deficit
 Weight loss
 Facial swelling or rash
 Vision disturbance
 Hearing loss/tinnitus/vertigo
 Unilateral nasal obstruction/discharge
 Possible causes of facial pain

Sinus disease (DM)

Local Dental caries/abscess/cyst
Salivary gland disorder such as sialolithiasis, mumps, parotitis
Temporomandibular disorders (TMDs)
Neoplasia (such as nasopharyngeal, brainstem)

Cranial Primary: trigeminal or glossopharyngeal nerve

neuralgia Secondary: intracranial

Giant cell arteritis (GCA)

Migraine
Vascular Cluster headache
Carotid artery dissection
Invasive fungal sinusitis
 Acute MI is a Headache

A 42-year-old male, with no history of coronary artery

disease or any other risk factor, including hypertension,
hyperlipidemia, smoking,or positive family history,
presented to a primary health center, complaining for
acute onset of severe headache beginning 4 h before. The
headache was located mainly frontally and bitemporally
and was constant with no periods of relief, even after
taking analgesics. Since the physical examination and
electrocardiogram were normal
no further evaluation was requested and the patient was
discharged home.
 What was wrong?

What was the diagnosis?

Did the patient improve before discharge?

Two hours later, the patient was admitted to the
emergency department complaining of persistent
headache.
On admission, he was conscious, well-orientated
and the vital signs and physical examination were
normal. The electrocardiogram showed a q wave
with mild ST elevation (1.2 mm) and inverted T
wave in the precordial leads V2-V5
Laboratory examination revealed the following abnormal
findings:
serum glucose 382 mg/dl
CK 336 U/I
CK-MB 32 U/l
LDH 459 U/I
Troponin 0.19 ng/ml
whereas the rest hematological and biochemical parameters
were normal.
The chest X-ray was also normal.
On the basis of the electocardiographic and cardiac enzyme
findings (i.e. elevated troponin, CK-MB) the diagnosis of an
AMI was established.
 What is the lesson here?

 AMI rarely presents by only Headache but

can happen.1
 AMI should be excluded in any case
presented by pain or discomfort above
epigastrium to forehead.
 AMI should be excluded in cases have CVD
risk factors.2
 AMI should be excluded in any new onset or
known migraine patient(masked MI)1
 A 45 yo female patient known to have migraine headache
presented to ER complaining of severe migraine attack since
2 hours, not resolved by usual migraine’s tablet the patient
used to use in the same attacks.
Examination was done revealed nothing significant
CT brain done and normal
ECG done revealing I, aVL, V5,V6 S-T elevation(lateral MI)
Cardiac enzymes was positive
Diagnosed as AMI
Patient admitted in CCU treated by thrombolytic therapy
Headache disappeared and ECG returned normal
 What is the lesson here?

 Women with migraine headache at

more risk for IHD.2

 Migraine treatment(sumatriptan)
can cause ACS in patient at risk.
Chest pain
 Red flag symptoms

 Exertional
 Sudden onset
 Dyspnoea
 Haemoptysis
 Significant unintentional weight loss
 New-onset dyspepsia if aged >55 years
 History of leg swelling, long flights or any recent
periods of immobility
 Migraine
 Possible causes
•Acute coronary syndrome
•Valvular heart problems, for example, aortic stenosis
•Pulmonary embolus
•Pneumonia
•Lung cancer
•Pneumothorax
•Dissecting thoracic aortic aneurysm
•Costochondritis
•Anxiety
 A 64 year old, semi-retired man, presented to ED
with 4-day history of left upper quadrant (LUQ)
pain. At triage, pain was described as sharp and
stabbing, worse on inspiration. Assessed by JMO, who
noted that there was mild pitting edema of the right
leg however the patient was not in respiratory distress.
Oxygen therapy, 2L via nasal prongs, was
commenced as the Sa02 had decreased from
96% to 93%.
FBC, EUC and coagulation levels were taken.
CXR report stated:
‘focal consolidation as well as mild volume loss
(left lower lobe). Acute setting the appearance may
be due to pneumonia‘
The JMO and Senior Registrar agreed that a CTPA was
warranted, however, after discussion with the Radiology
Registrar and then with the ED Staff Specialist, the
decision was made to await the pathology results.
Results: elevated Neutrophils (11.2), WCC
(14.6) and CRP (214).
Following discussion amongst the ED team, the
decision was made not to request the CTPA but
to treat as pneumonia.( What is the error here?)
Plan included administration of intravenous
antibiotics and monitoring of observations.

Patient was transferred into the HDU, oxygen therapy

was removed and Sa02 was 94% on room air.
The patient was discharged on oral antibiotics and
analgesia following the evening medical handover.
Eight days later, the patient was found unconscious at
work and brought to the ED by ambulance.
Resuscitation was unsuccessful.

The Coroner's office report stated that the cause

of death was attributed to:
“Bilateral pulmonary thromboembolism with
the underlying condition of DVT, right leg”
 PE may present in an atypical manner, with
concurrent lower respiratory tract infection.

If you have a high clinical suspicion of a PE,

ensure it’s ruled out before committing to an
alternative diagnosis.
 A 28 year old fit and well female presented to ED
in the early morning following onset of pain under left
lower breast.
Pain reported to be reproducible on movement and
with inspiration.
Triage nursing staff recorded patient being on nil
medications. It was later discovered that the
patient was on the OCP.
 Vitals:
 HR 76/min
 BP 95mmHg systolic
 RR 18
 SaO2 98% RA.
Given paracetamol and ibuprofen, and triage
category 4.
On review, patient’s pain had resolved 30mins after initial
presentation.

ECG performed, which showed sinus tachycardia at HR 110.

Patient seen by ED Registrar in Fast Track area, unmonitored.
Noted that the patient “awoke with sharp left chest pain. Unable to
breathe easily. Never happened before. Denies abnormal physical
activity. No cardiac history. No PE risks.
Pain coming from underneath the breast
radiating to the left side. Much improved since
ibuprofen and paracetamol”.
Vital signs repeated, and were normal.
Diagnosis of musculoskeletal chest pain given and
patient discharged home.
Two weeks later, patient presented to ED in
cardiac arrest after losing consciousness whilst
her father drove her to hospital. Following nearly an
hour of CPR, patient had return of spontaneous
circulation and was transferred to ICU.
 CTPA performed, which showed
massive pulmonary embolus with associated
hemorrhage and infarction.
 If a patient has chest pain, a possible life-
threatening differential diagnosis could be a
PE.3

Consider their risk factors and apply clinical

decision rules to exclude a
PE, before attributing symptoms to a
musculoskeletal aetiology
Abdominal pain
 Red flag symptoms
• Sudden onset abdominal  Bloodstained vaginal
pain discharge
• Haematemesis  Pre-syncopal symptoms
• Unexplained weight loss  Haematuria
• Change in bowel habit for >  Fever
3 weeks  New onset dyspepsia
• Unexplained PV bleeding  Persistent unexplained
• Post-coital bleeding vomiting
• Shortness of breath  Amenorrhoea
• Dysphagia  Testicular pain
• Increased vaginal discharge  Elderly
 Potentially life-threatening diagnoses

 MI  Bowel obstruction
 Perforated viscus  Diabetic ketoacidosis
 Ruptured abdominal  PID
aortic aneurysm  Incarcerated inguinal
 Ectopic pregnancy hernia
 Acute pancreatitis  Pyelonephritis
 Acute cholecystitis  Ischemic colitis
 IBD  Acute hepatic failure
 Renal stone  Appendicitis
 Diverticulitis
 HISTORY REPEATs ITSELF?

 A 50yo female presented to ED with a three-day history of

abdominal pain and vomiting. Background included
previous appendectomy, similar episodes of self-limiting
abdominal pain for which a cause remained undetermined.
Reported pain usually occurred after eating food from
takeaway outlets.
Patient presented clutching her abdomen. Triage nurse noted
abdominal tenderness / bloating, but soft. Vital signs were
as follows: • BP 165/105mmHg • HR 124/min • RR 36/min
What is going on?
Patient given IV fluids for rehydration and morphine
for pain relief. These had good effect, and vital signs
improved to be within acceptable parameters.
X-Rays arranged – inconclusive.
Seen by medical officer. Pain described as similar to
previous presentations.
Provisional diagnosis: Gastroenteritis/Colitis in keeping
with patient’s past history.
Management plan: monitor fluid balance, CT abdomen,
nasogastric tube (NGT) insertion.
Do you agree with the patient’s
provisional diagnosis and
management plan?
Patient declined NGT insertion and her
wishes were respected as there was no active
vomiting. CT delayed and ultimately
postponed until the following day. Patient
remained in the ED overnight whilst waiting
for CT to be performed, during which time
observation frequency is changed from
hourly to fourth hourly.
The next morning, CT abdomen demonstrated
significantly distended fluid filled bowel loops
with collapsed loops of distal and terminal ileum.
On return to ED, patient noted to be diaphoretic
and pale. She vomited and progressed to
cardiorespiratory arrest. CPR commenced with
eventual return of spontaneous circulation.
Following multiple operations and prolonged
period on life support, patient died.

Cause of death: aspiration pneumonitis

secondary to small bowel
obstruction/necrosis caused by stricture.
 What is the lesson here?

Any patient who re-presents from any

site of medical care (not just ED) for the
same problem should not be dismissed.
Ask the patient: “Have you seen a doctor or
been to an ED for this problem before?”

If so, and over a short space of time, this is

a RED FLAG.
 In their systematic review, LaCalle et al. concluded
that:
frequent ED users tend to be sicker than
occasional users, and are often sick patients
with chronic illness associated with high
admission rates and high mortality.

This evidence suggests that patients who

present to ED on a frequent basis are a
medically vulnerable group.
 GUT FEELING

A 76yo male was brought into a local district hospital ED by

ambulance at midnight with abdominal pain.
The paramedics report the observations were found to be in
normal range except for BP 170/80 and pain score 7/10.
He complained of constipation and abdominal pain for 4
days, described as sharp in nature, but had increased
significantly overnight prompting his relatives to call an
ambulance.
He was given morphine for analgesia.
Observations were unchanged from time of ambulance
assessment.
Within 30mins, patient was reviewed by a medical officer and
given a provisional diagnosis of constipation.
Patient was given analgesia and a fleet enema, which resulted in
a small bowel motion.
Nil further analgesia was given as ambulance morphine had
successfully eased the pain
At 0200, there was discussion between medical staff and the
patient and carer regarding patient’s disposition. A plan was to
discharge the patient home and have them return later in the
morning for further investigation.
At 0230, patient was discharged home into the care of his family.
Patient returned to attend a CT later in the day.
Whilst in the radiology department, patient collapsed at 1130. On
arrival of the Rapid Response Team, patient found to have GCS
3.
Patient was given fluid bolus with improvement of GCS to 14 by
the time the patient was transferred to ED.
On examination, patient noted to be pale, cold and clammy with
a pulsatile abdominal mass palpable in the patient’s epigastric
region.
Patient received further fluid resuscitation and transfusion of
four units of blood.
At 1330, patient was transferred to a tertiary facility for
consideration of urgent definite management.
During transit in the ambulance, patient suffered a
cardiorespiratory arrest.
With respect to patient and family’s previously discussed
wishes, CPR was not commenced and patient returned to
referring hospital for certification.
Cause of death found to be due to: ruptured AAA.
 What is the lesson here?

 Elderly abdominal pain patients are more likely to

present with vague and nonspecific symptoms
while harboring serious disease processes.4
 For elderly patients with abdominal pain, it is NOT
constipation or gastroenteritis until other serious
diagnoses have been actively sought and excluded.4
 Any patient over 50 years of age with suspected
renal colic should have the diagnosis of ruptured
AAA explicitly sought and excluded.
THROWN A CURVEBALL
A 17yo male presented to ED with 30-minute history of sudden onset right
iliac fossa pain and associated vomiting.
At triage, observations:
 T35C
 HR 94/min, regular
 BP 128/81
 SaO2 97% RA
Abdomen soft with mild guarding.
Given triage category 4.
30mins after presentation, patient did not answer a call from nursing
staff.
Officially documented as “Did not wait for treatment” two hours after
presentation.
12 hours after initial presentation, patient re-presented with
vomiting, severe right iliac fossa and right testicle pain.
Given triage category 2.
Reviewed by medical officer, ultrasound arranged and Urology
Registrar informed of patient’s arrival.
An ultrasound was completed, demonstrating poor right testicular
blood flow.
Proceeded to OT for scrotal exploration +/- orchidectomy.
In theatre, patient found to have necrotic R testicle with 720 degree
torsion.
Right orchidectomy was performed.
 What is the lesson here?

Always examine the scrotum for

testicular torsion in the young
male with abdominal, groin or
penile pain.
 Patients with testicular torsion do not always present with
the pathognomic history of “acute excruciating
scrotal pain of relatively short duration”.
Testicular torsion should always be included in
differential diagnosis when evaluating lower
abdominal pain in young males.

The external genital organs should be

examined in every child or adolescent with
acute abdominal pain.
 Presenting with only abdominal or inguinal pain
is not an uncommon presentation for testicular
torsion, with abdominal pain often preceding and
exceeding scrotal pain. Cass et al. reported that
12.5% of patients with testicular torsion
presented with only abdominal or inguinal pain,
while a 25-year review of testicular torsion cases
in Bristol found that 6% of cases presented with
inguinal pain alone.
 Conclusions
 Using the clinical warning criteria (red flags) is a
must in all medical areas.

 In your daily practice the single most important task

is to exclude critical conditions.

 It is important to trace the Pitfalls in your practice

 Safety of your patients much more important than

the accuracy of the diagnosis
 REFERENCES
1. Amendo MT, Brown BA, Kossow LB, Weinberg FM. Headache as the sole
presentation of acute myocardial infarction in two elderly patients. Am J
Geriatr Cardiol. 2001;10:100–1
2. Auer J, Berent R, Lassnig E, Eber B. Headache as a manifestation of
fatal myocardial infarction. Neurol Sci. 2001;22:396–7.
3. Mårten Söderberg; Ulla Hedström; Malgorzata Sjunnesson; Gerd
Lärfars; Christina Jorup-Rönström. Initial symptoms in pulmonary
embolism differ from those in pneumonia: a retrospective study
during seven years. European Journal of Emergency Medicine.
13(4):225-229, AUG 2006.
4. [Guideline] LeFevre ML, U.S. Preventive Services Task Force.
Screening for abdominal aortic aneurysm: U.S. Preventive Services
Task Force recommendation statement. Ann Intern Med. 2014 Aug
19. 161 (4):281-90.
Thank you
 PRETEST & POSTTEST

1. A 40 year old gentleman, diabetic (uncontrolled), who

presented with a right cheek pain progressively over a
15-day period. Patient also reports associated
headache, blurring of vision in the right eye. Patient
had no fever, chills, or nasal discharge. On physical
exam he had tenderness over right cheek & blocked
right side of the nose His blood sugar was 465 mg/dl
upon presentation. CT scan of sinuses and neck was
done and showed an aggressive soft tissue lesion in the
right maxillary sinus with erosion of the anterior and
lateral wall of the maxillary sinus, and erosion of the
orbital floor on the right side with invasion of the
inferior aspect of the right orbit.
Q what is the Red flag in this case?
A 45 y old female patient with known migraine on
treatment presented in ED by acute attack of headache
not improved with analgesic what is appropriate next
step
1-Discharge the patient with prescribed analgesia.
2-Give her a tramadol 100mg IM to abort the pain
then discharge.
3- Admit her under observation and request ECG and
cardiac enzymes.