Category: Pharmacology & Therapeutics
Keywords: penicillin, beta-lactam, antibiotic stewardship, allergy, hypersensitivity (PubMed Search)
Posted: 2/13/2025 by Matthew Poremba
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Background:
Approximately 10% of patients presenting to the emergency department (ED) report penicillin allergies, which may lead to use of second- or third-line agents. Alternative therapies (such as aztreonam, clindamycin and fluroquinolones) carry an increased risk of mortality and complications such as Clostridioides difficile infection. Considering that less than 10% of penicillin allergies may be confirmed by formal testing results, the PEN-FAST clinical decision tool was created to identify patients with low risk of true penicillin allergy who do not require formal skin testing for rechallenging with a beta-lactam:
Though PEN-FAST has only been validated in the clinic and inpatient settings, a study from Tran et al. published this January sought to determine the safety and efficacy of utilizing this tool to assess penicillin allergies and re-challenge patients in the ED.
Study design:
This was a single-center, prospective, observational cohort study. Emergency medicine (EM) pharmacists screened patients in the ED with:
Screened patients were excluded from the study if orders were placed by a non-EM physician, if they previously tolerated a penicillin/cephalosporin within the healthcare system of the study site, if they were unable to participate in bedside interview, if the antibiotics selected were appropriate despite the penicillin allergy or if there were time constraints that would delay care if the PEN-FAST assessment needed to be completed.
Study Intervention:
EM pharmacists completed the PEN-FAST assessment for all included patients. They recommended rechallenging with an appropriate beta-lactam for patients with a score of 0-2, recommended to consider rechallenging for patients scoring 3, and did not recommend rechallenging for scores of 4-5 or if it was confirmed patients previously experienced anaphylaxis, angioedema or severe cutaneous reactions with a beta-lactam. Orders for any change in therapy were only placed with discussion and agreement from EM physicians. Rechallenged patients were assessed at bedside for any immune-mediated reactions 45 to 75 minutes after initiation of antibiotics. The primary outcome was the percent of patients with a PEN-FAST score of 0-2 who tolerated a beta-lactam after being rechallenged.
Patient Characteristics:
After screening, one hundred patients were included in this study.
Results:
Primary Outcome:
Secondary Outcomes:
Key Takeaways:
Category: Critical Care
Posted: 2/11/2025 by Jordan Parker, MD
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Background
Diagnosed by continuous seizure activity that lasts for 5 minutes or more and/or multiple seizures that occur without returning to baseline in-between each. Further classified as being convulsive or non-convulsive. Refractory status epilepticus can be defined as status epilepticus that does not respond to an adequately dosed benzodiazepine and another anti-seizure medication. The primary objective in management is to stop both clinical and electrographic seizures which can become an important point for those patients who require intubation and receive neuromuscular blockade. Essential to evaluate early for reversible causes (electrolytes, liver function, glucose, ammonia, medications) and for other precipitating causes with toxicology screening and CT head imaging with consideration for angiography and venography.
Management:
First-Line/Initial Therapy:
Lorazepam IV 0.1 mg/kg up to 4 mg per dose is the preferred agent, can be repeated after 5 minutes if seizures persist
Diazepam 0.15 mg/kg IV/0.2 mg/kg PR up to 10 mg, or midazolam IM 0.2 mg/kg up to 10 mg are also alternatives
Second-line/Urgent control: (Provided to all patients with SE after initial therapy)
- Levetiracetam 60 mg/kg, Valproate 40 mg/kg, and fosphenytoin 20 mgPE/kg were studied by Kapur et al., and they found similar rates of resolution of status epilepticus with similar rates of adverse events.
- Phenobarbital 15-20 mg/kg is another agent that has good efficacy and is remerging as an effective agent. Can cause respiratory depression at high doses.
- Keppra may have the best side-effect profile to consider.
- Valproate can cause hepatotoxicity, elevated ammonia and thrombocytopenia.
- Fosphenytoin can cause hypotension and arrhythmias.
Third-line:
Midazolam 0.2 mg/kg load followed by 0.05 – 2 mg/kg/hr infusion
Propofol 1-2 mg/kg load followed by 20-200 mcg/kg/min infusion
Ketamine 0.5 – 3 mg/kg load followed by 1.5-10 mg/kg/hr infusion
Pentobarbital 5 mg/kg load followed by 0.5-5 mg/kg/hr infusion
- Propofol carries the risk of propofol infusion syndrome with high doses or prolonged infusions, some favor midazolam because of this.
No conclusive data to support one over another.
Important Considerations
- A common mistake is to under-dose benzodiazepines for initial therapy, give the full weight-based dose as described above.
- Following initial management it is important to monitor patients with continuous EEG if they have not returned to their neurologic baseline
- Propofol, midazolam or ketamine are good options for induction for intubation.
- Consider against using etomidate for induction of intubation since it can cause myoclonus which can complicate the picture if you are already worried about seizures, can be hard to differentiate.
- If intubation is required and EEG is not readily available consider reversal of neuromuscular blockade after intubation to better monitor for continued seizures.
- If in refractory status epilepticus despite using a second-line agent and a third line agent then consider adding a second agent from the second-line/urgent control that was not previously started (fosphenytoin, valproate, levetiracetam, or phenobarbital).
Brophy GM, Bell R, Claassen J, Alldredge B, Bleck TP, Glauser T, Laroche SM, Riviello JJ Jr, Shutter L, Sperling MR, Treiman DM, Vespa PM; Neurocritical Care Society Status Epilepticus Guideline Writing Committee. Guidelines for the evaluation and management of status epilepticus. Neurocrit Care. 2012 Aug;17(1):3-23. doi: 10.1007/s12028-012-9695-z. PMID: 22528274.
Jennifer V Gettings, Fatemeh Mohammad Alizadeh Chafjiri, Archana A Patel, Simon Shorvon, Howard P Goodkin, Tobias Loddenkemper. Diagnosis and management of status epilepticus: improving the status quo. The Lancet Neurology. 2025;24(1):65-76.
Kapur J, Elm J, Chamberlain JM, Barsan W, Cloyd J, Lowenstein D, Shinnar S, Conwit R, Meinzer C, Cock H, Fountain N, Connor JT, Silbergleit R; NETT and PECARN Investigators. Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. NEJM. 2019 Nov 28;381(22):2103-2113. doi: 10.1056/NEJMoa1905795.
Category: Obstetrics & Gynecology
Keywords: postpartum hemorrhage, TXA (PubMed Search)
Posted: 2/8/2025 by Jennifer Wang, MD
(Updated: 2/10/2025)
Click here to contact Jennifer Wang, MD
In the last few months, there have been multiple articles published regarding the use of prophylactic TXA to prevent postpartum hemorrhage. While almost none of us want to ever be in the situation where we have to deliver a baby in the ED, we need to be prepared for all outcomes.
A meta-analysis by Ker et. al (Oct 2024) and a RCT, blinded study by Zhang et. al (Dec 2024) both demonstrated that giving 1g TXA immediately after delivery of a baby can reduce the rate of severe postpartum hemorrhage in patients with risk factors. These studies had a wide variety in what they considered risk factors, but a few that showed particular significance included: hx of postpartum hemorrhage, history of anemia, gestational diabetes, and placental adhesion.
So next time you've scooped that screaming baby out into your already chaotic emergency department, ask your patient (not the baby) a few questions about their birth history and think about giving 1g of TXA to prevent a horror show for whoever is coming on for you next.
Caveat: These studies were done in delivery rooms and not emergency rooms, but I think we can extrapolate since it would be very hard to find enough patients to conduct a study like this in the emergency department.
Ker K, Sentilhes L, Shakur-Still H, Madar H, Deneux-Tharaux C, Saade G, Pacheco LD, Ageron FX, Mansukhani R, Balogun E, Brenner A, Prowse D, Arribas M, Ahmadzia H, Chaudhri R, Olayemi O, Roberts I; Anti-fibrinolytics Trialists Collaborators Obstetric Group. Tranexamic acid for postpartum bleeding: a systematic review and individual patient data meta-analysis of randomised controlled trials. Lancet. 2024 Oct 26;404(10463):1657-1667. doi: 10.1016/S0140-6736(24)02102-0. PMID: 39461793.
Zhang P, Jia YJ, Lv Y, Fan YF, Geng H, Zhao Y, Song H, Cui HY, Chen X. Effects of tranexamic acid preconditioning on the incidence of postpartum haemorrhage in vaginal deliveries with identified risk factors in China: a prospective, randomized, open-label, blinded endpoint trial. Ann Med. 2024 Dec;56(1):2389302. doi: 10.1080/07853890.2024.2389302. Epub 2024 Aug 12. PMID: 39129492; PMCID: PMC11321115.
Category: Cardiology
Keywords: Hypertension, as needed, acute kidney injury (PubMed Search)
Posted: 2/9/2025 by Robert Flint, MD
(Updated: 2/15/2025)
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A retrospective look at veterans who received oral and/or IV as needed blood pressure medications while hospitalized in a non-ICU setting found an association with as needed meds and acute kidney injury, greater than 25% blood pressure drop in 3 hours, and death, stroke and MI while hospitalized. IV medications had a higher association.
While needing prospective validation, this appears to be more evidence to treat the patient not the number.
Canales MT, Yang S, Westanmo A, Wang X, Hadley D, Ishani A, Mohandas R, Shorr R, Lo-Ciganic W. As-Needed Blood Pressure Medication and Adverse Outcomes in VA Hospitals. JAMA Intern Med. 2025 Jan 1;185(1):52-60. doi: 10.1001/jamainternmed.2024.6213. PMID: 39585709; PMCID: PMC11589853.
Category: Orthopedics
Posted: 2/8/2025 by Brian Corwell, MD
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Spondylolysis is a fracture of the pars interarticularis.
The prevalence has been reported to be between 4 and 8% of all children.
It is thought to be even more common in athletes.
With more young athletes specializing earlier and participating in year-round sports, spondylolysis is being seen in younger children.
Most often, repetitive stress from activities requiring excessive lumbar extension is contributory
Sports at increased risk include: gymnastics, baseball, football (linemen & linebackers), dancers, weightlifters
Spondylolysis is thought to be responsible for almost 50% of back pain in this population!
Commonly involves L5.
When these fractures occur bilaterally the superior vertebral body can translate anteriorly on the vertebrae below, a process called spondylolisthesis.
Unlike most causes of back pain that are worse with flexion, patients will often have increased pain with extension.
-Back extension loads the posterior elements of the spine.
Treatment focuses on modifying activities that cause pain, avoid back extension, NSAIDs for pain control and physical therapy for improved core strengthening & flexibility.
For athletes, initial recommendation is for a six-week period of rest
Category: Critical Care
Keywords: OHCA, cardiac arrest, ROSC, post-arrest syndrome, post-arrest care (PubMed Search)
Posted: 2/5/2025 by Kami Windsor, MD
(Updated: 2/15/2025)
Click here to contact Kami Windsor, MD
For those of us living in a world where ED boarding is a reality and ICU beds are in short supply, a re-up on the basic tenets of post-arrest care to optimize survival and neurologic outcomes in patients with sustained ROSC after OHCA:
Category: Ultrasound
Keywords: aorta; POCUS; aortic dissection (PubMed Search)
Posted: 2/3/2025 by Alexis Salerno, MD
Click here to contact Alexis Salerno, MD
The suprasternal notch view is a valuable tool for assessing the aorta and identifying signs of thoracic aortic dissection. Proper technique is essential to obtain a clear image and improve diagnostic accuracy.
Steps to Obtain the Suprasternal Notch View:
Position the Patient:
Ideally, place the patient in a supine position.
If the patient cannot tolerate lying flat, the scan can be performed with the patient in an upright position.
Probe Selection & Orientation:
Use a phased array probe in cardiac mode.
Direct the probe marker slightly toward the patient’s left shoulder (or right hip if using abdominal mode).
Optimize Patient Positioning:
Ask the patient to extend their neck to improve visualization.
Having the patient rotate their head to the side may further enhance imaging.
Placing a rolled towel under the shoulders can help achieve optimal neck extension.
Probe Manipulation:
Angle the probe inferiorly toward the chest.
Adjust the depth to clearly visualize the aortic arch.
Kinnaman KA, Kimberly HH, Pivetta E, Platz E, Chudgar A, Adduci A, Stone MB, Rempell JS. Evaluation of the Aortic Arch from the Suprasternal Notch View Using Focused Cardiac Ultrasound. J Emerg Med. 2016 Apr;50(4):643-50.e1. doi: 10.1016/j.jemermed.2015.12.002.
Category: Infectious Disease
Keywords: Risk, soft tissue, infection (PubMed Search)
Posted: 1/30/2025 by Robert Flint, MD
(Updated: 2/2/2025)
Click here to contact Robert Flint, MD
Risk factors for necrotizing soft tissue infections include: obesity, diabetes mellitus, peripheral vascular disease, immunosuppression, injection drug use, and deep traumatic wounds.
“Any anatomical site can be involved, but the most common sites are perineal, anorectal, foot, or lower extremities.”
Category: Trauma
Keywords: Cervical sound, age, geriatric, trauma, clearance (PubMed Search)
Posted: 2/1/2025 by Robert Flint, MD
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Not based on currently available literature.
This editorial reminds us that the only evidenced based screening criteria we have for C-spine clearance in those over age 65 after trauma is the Canadian C-Spine Rule (2002). This rule recommends imaging for all patients over age 65. No large, well done study indicates physical exam or other means can be used to clear C-Spines in those over age 65.
Rodriguez R, Greenberg S. Is older age an appropriate criterion alone for ordering cervical spine CT after trauma. Acad Emerg Med. 2024; 00: 1-2. doi:10.1111/acem.15001
Category: Pediatrics
Keywords: pediatric trauma, abdominal trauma, imaging (PubMed Search)
Posted: 1/31/2025 by Rachel Wiltjer, DO
Click here to contact Rachel Wiltjer, DO
PECARN, in 2012, published a decision tool aimed at helping avoid unnecessary abdominal CT scans in children with blunt torso trauma. While a prior retrospective validation was done, the tool had not been prospectively validated and generally has not been in widespread use as a standalone, although the original paper may have helped to influence development of local pediatric trauma protocols. Recent prospective validation may make the tool more applicable for broader usage.
The tool is useful as a rule out given that when all criteria are negative, the risk of intraabdominal injury requiring intervention is less than 0.1%. The criteria are:
If using the rule, it is important to note that the presence of one or more of the criteria does not indicate that the patient needs a CT. Patients who do not rule out should be evaluated based on local pediatric trauma protocols and/or in collaboration with the local pediatric trauma center, which often will involve a stepwise approach based on historical information, laboratory workup, and physical exam findings.
Holmes JF, Yen K, Ugalde IT, et al. PECARN prediction rules for CT imaging of children presenting to the emergency department with blunt abdominal or minor head trauma: a multicentre prospective validation study. Lancet Child Adolesc Health. 2024;8(5):339-347. doi:10.1016/S2352-4642(24)00029-4
Category: Infectious Disease
Keywords: Soft tissue infection (PubMed Search)
Posted: 1/30/2025 by Robert Flint, MD
(Updated: 2/15/2025)
Click here to contact Robert Flint, MD
These infections remain difficult to diagnose early and early diagnosis is key to limiting morbidity and mortality.
“The classic clinical signs and symptoms are rarely all present especially in early disease. Crepitus or gas in the soft tissues, while specific, is only present in approximately 10% of patients. More often, the presenting symptoms are nonspecific: fever, pain, induration, and edema. Pain out of proportion to examination is a more specific finding that may assist in differentiation of NSTI from cellulitis.”
Bisgaard, Erika K. MD; Bulger, Eileen M. MD
Journal of Trauma and Acute Care Surgery 97(5):p 678-686, November 2024. | DOI: 10.1097/TA.0000000000004351
Category: Critical Care
Keywords: OHCA, cardiac arrest, IV, intravenous, IO, intraosseous, epinephrine (PubMed Search)
Posted: 1/29/2025 by Kami Windsor, MD
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Two recent studies (see “Additional Information” for more study details) published in the New England Journal of Medicine evaluated the outcomes of OHCA, comparing drug administration via intraosseous devices versus intravenous access, neither demonstrating benefit to one strategy over the other in terms of sustained ROSC or 30-day survival. [1,2] While there were a few limitations, these results are generally in line with existing literature. Although it is worth noting that some studies signal improved outcomes with IV access, the time to intervention seems to be the more important metric related to outcome. [3-5]
Bottom Line: Intraosseous devices remain rapid and easy to place devices that can provide access for drug administration when IV access is unable to be obtained. In patients with difficult access, use an IO to administer meds, fluids, or blood products as indicated while you and your team work on more definitive IV access and focus on high-quality CPR.
Couper et al.
Vallentin et al.
Category: Trauma
Keywords: Chest trauma, ketorolac, ketamine (PubMed Search)
Posted: 1/26/2025 by Robert Flint, MD
(Updated: 2/15/2025)
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This small study randomized patients with 2 or greater rib fractures or requiring chest tube insertion into a kerorolac (30 mg) or ketamine (0.25 mg/kg) group and evaluated pain levels pre, 30 and 60 minutes post medication administration. They also looked at need for morphine rescue medication. The ketamine group had superior pain control and required less rescue medication.
Hossein Zabihi Mahmoodabadi MD, Zeynab Seyed Javadein MD, Fatemeh Moosaie MD, MPH, Ali Faegh, Maryam Bahreini MD
First published: 31 December 2024
Category: Orthopedics
Posted: 1/25/2025 by Brian Corwell, MD
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“Hey Doc, do I knee surgery?”
Distal radius fractures are one of the most common orthopedic injuries
Usual mechanism is FOOSH
Treatment can be nonoperative or operative depending on multiple factors including fracture stability, displacement in addition to functional demands and age.
Non operative general indications include:
Extra-articular
< 5mm radial shortening
Dorsal angulation < 5° or <20° of contralateral distal radius
Factors where surgery is considered
Fractures assoc. w/ large ulnar styloid fractures (most or all) are at increased risk of DRUJ instability
Intra-articular displacement (step-off) particularly if greater than 2mm
Increased dorsal tilt/angulation (greater than 10° from neutral)
Radial shortening >3mm
In patients >65yo, dorsally displaced fractures can generally be primarily managed non-operatively unless there is significant deformity or neurological compromise.
Category: Administration
Keywords: Burnout, Wellbeing, Workforce (PubMed Search)
Posted: 1/22/2025 by Mercedes Torres, MD
(Updated: 2/15/2025)
Click here to contact Mercedes Torres, MD
On March 18, 2022, Congress passed the Dr. Lorna Breen Health Care Provider Protection Act, named after an emergency medicine physician who died by suicide during the pandemic. This landmark legislation allocated $103 million across 45 organizations to introduce evidence-based measures to mitigate and prevent burnout.
As a result, the Impact Wellbeing Guide was developed, outlining the six key evidence-based action steps for organization leaders to address health care workers’ professional well-being listed below:
The Guide is designed to help hospital leaders and executives accelerate or supplement professional wellbeing work in their hospitals at the operational level.
A PDF of the full guide is available from the CDC: https://www.cdc.gov/niosh/docs/2024-109/
https://www.cdc.gov/niosh/healthcare/impactwellbeingguide/
Bock A. To Fix Burnout, New Initiatives Go Beyond Worker Resilience and Put Onus on Health Systems. JAMA. 2024;331(24):2067–2069. doi:10.1001/jama.2024.6216
Category: Critical Care
Keywords: delirium, ICU, window (PubMed Search)
Posted: 1/21/2025 by Quincy Tran, MD, PhD
(Updated: 2/15/2025)
Click here to contact Quincy Tran, MD, PhD
Delirium in the ICU means badness as delirious ICU patients are associated with longer stay and higher mortality. While medications are not proven to prevent delirium, certain environmental interventions such as window access, light and sound levels have been recognized as legit interventions to prevent ICU delirium.
Settings: This is a retrospective study at Massachusetts General Hospital
Participants: 3527 patients admitted to a surgical ICU between 2020 and 2023.
Outcome measurement: This study hypothesized that patients in a windowed ICU room will have lower rates of delirium, decreased ICU length of stay, hospital LOS. Multivariable logistic regressions were performed for the association of clinical variables and the presence of delirium.
Study Results:
Delirium was observed in 460 patients (21%) of the windowed rooms group and 206 patients (16%) of the nonwindowed rooms group. Multivariable logistic regression showed that patients in windowed rooms were associated with higher odds of delirium (aOR, 1.29; 95% CI, 1.07–1.56; p = 0.008), although they were not associated with longer ICU LOS or longer HLOS
Discussion:
The study’s findings added to the literature that natural lighting might not be the effective prevention of delirium. The presence of windows might not be the answer.
In this study, all the windows were facing another building, and there was no view of other natural scenes, with a limited view of the sky. Therefore, the authors suggested that the overall quality of the windows would be more important.
Conclusion:
The ICU environment is more important for patients’ delirium than just the presence of windows.
Anderson DC, Warner PE, Smith MR, Albanese ML, Mueller AL, Messervy J, Renne BC, Smith SJ. Windows in the ICU and Postoperative Delirium: A Retrospective Cohort Study. Crit Care Med. 2025 Jan 13. doi: 10.1097/CCM.0000000000006557. Epub ahead of print. PMID: 39791968.
Category: Ultrasound
Keywords: POCUS, ventricular arrythmia, nerve blocks (PubMed Search)
Posted: 1/20/2025 by Alexis Salerno, MD
Click here to contact Alexis Salerno, MD
Stellate Ganglion Blocks (SGB) have been reported in case reports as a last-line treatment for patients with refractory ventricular arrhythmias.
A recent multicenter study evaluated the efficacy and safety of SGB in managing refractory ventricular arrhythmias.
The study included 117 critically ill patients, with 9 on ECMO, 5 with Impella devices, and 15 with LVADs.
70% were given long-acting bupivacaine, 28% were given ropivacaine and 1 patient received lidocaine.
SGBs were primarily performed by anesthesiologists during short periods of when the patients were not in ventricular arrhythmia
The median 24-hour episodes of VT/VF decreased from 9.0 (interquartile range [IQR]: 3.0–31.0) pre-SGB to 1.0 (IQR: 0.0–5.0) post-SGB.
2 patients had complications; recurrent laryngeal nerve block with resultant hoarseness and brachial plexus block.
Limitations: This study was conducted in a controlled setting (ie not in active arrest, not in the emergency department) and involved a selective cohort. Randomized controlled trials (RCTs) are needed to validate these findings.
Chouairi F, Rajkumar K, Benak A, Qadri Y, Piccini JP, Mathew J, Ray ND, Toman J, Kautzner J, Ganesh A, Sramko M, Fudim M. A Multicenter Study of Stellate Ganglion Block as a Temporizing Treatment for Refractory Ventricular Arrhythmias. JACC Clin Electrophysiol. 2024 Apr;10(4):750-758. doi: 10.1016/j.jacep.2023.12.012.
Category: Trauma
Keywords: occipital, condyles, fracture, cervical spine (PubMed Search)
Posted: 1/19/2025 by Robert Flint, MD
Click here to contact Robert Flint, MD
Fractures of the occipital condyles are a relatively rare injury that occur in high energy blunt mechanisms (IE roll over MVC) most commonly. Physical exam will show signs of basilar skull fracture and significant pain at the base of the skull/upper C-spine. CT scan is the gold standard to make the diagnosis. Look for signs of upper extremity weakness on physical exam or cranial nerve injuries. Those type of findings should also prompt emergent MRI evaluation. Treatment generally is long term immobilization in a collar however Type 3 and those with neurologic findings may require surgical intervention.
Anderson and Montesano Classification
Type I 3% of occipital condyle fracturesImpaction-type fracture with comminution of the occipital condyle
Due to compression between the atlantooccipital joint
Stable injury due to minimal fragment displacement into the foramen magnum
Type II 22% of occipital condyle fracturesBasilar skull fracture that extends into one or both occipital condyles
Due to a direct blow to skull and a sheer force to the atlantooccipital joint
Stable injury as the alar ligament and tectorial membrane are usually preserved
Type III 75% of occipital condyle fractures Avulsion fracture of condyle in region of the alar ligament attachment (suspect underlying occipitocervical dissociation)
Due to forced rotation with combined lateral bending
Has the potential to be unstable due to craniocervical disruption
Category: Pediatrics
Keywords: sedation, airway, preoxygenation (PubMed Search)
Posted: 1/17/2025 by Jenny Guyther, MD
(Updated: 2/15/2025)
Click here to contact Jenny Guyther, MD
This was a retrospective, multicenter cross-sectional study of pediatric sedations over 3 years using the Pediatric Sedation Research Consortium database.
85,599 pediatric sedations were included. These sedations did include the operating rooms.
8.7% of sedations required an intervention for airway/breathing/circulation in patients who did NOT have procedural oxygenation while 10.1% of patients in the group that did have procedural oxygenation required an intervention. The majority of these interventions were minor, ie airway repositioning. The group that did have procedural oxygenation did have a lower rate of hypoxia compared to the group without procedural oxygenation (2.5% vs 4.5%).
The authors concluded that preemptive procedural oxygenation did NOT decrease the overall need for interventions in the ABCs compared to no procedural oxygenation.
Li J, Krauss B, Monuteaux MC, Cavallaro S, Fleegler E. Preprocedural Oxygenation and Procedural Oxygenation During Pediatric Procedural Sedation: Patterns of Use and Association With Interventions. Ann Emerg Med. Published online June 12, 2024. doi:10.1016/j.annemergmed.2024.04.014
Category: Neurology
Keywords: Baclofen withdrawal, baclofen pump, dysautonomia (PubMed Search)
Posted: 1/16/2025 by Nicholas Contillo, MD
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Intrathecal baclofen pumps are increasingly used to manage spasticity in patients with conditions such as cerebral palsy, spinal cord injury, multiple sclerosis, traumatic brain injury, and other dystonias. The most common causes of baclofen pump dysfunction include pump-related issues (e.g., programming errors, battery failure), catheter problems (e.g., extra-thecal dislodgement, kinking, leaks), and medication depletion (e.g., overdue or insufficient refills). Symptoms of dysfunction can be nonspecific, ranging from mild (spasticity, dysphoria, dysesthesias) to severe (e.g., rigidity, rhabdomyolysis, seizures, fever, autonomic dysfunction, cardiomyopathy).
Once dysfunction is recognized, management involves stabilizing vital functions (ABCs, temperature management, fluids), administering multimodal antispasmodics (enteral or parenteral baclofen, benzodiazepines, dexmedetomidine, tizanidine), and performing pump interrogation, often in collaboration with neurology or PM&R specialists. Restoration of intrathecal flow is the preferred and definitive therapy; however, patients with severe withdrawal may require aggressive temporizing measures including intubation. Some authors describe intrathecal baclofen administration via lumbar puncture as a rescue measure for severe cases with limited access to definitive care. Imaging with plain radiographs, fluoroscopy, or CT may be indicated in select cases where there is concern for catheter displacement or kinking, and some patients may require surgical revision.
Takeaway: Consider baclofen withdrawal in patients on chronic baclofen therapy who present with nonspecific symptoms that may mimic conditions such as alcohol withdrawal, delirium, sympathomimetic toxicity, neuroleptic malignant syndrome, serotonin syndrome, thyrotoxicosis, rhabdomyolysis, sepsis, or status epilepticus. In cases of intrathecal pump dysfunction, the definitive treatment is restoration of baclofen flow, so involve consultants early for pump interrogation while temporizing with supportive measures.