Keywords: URI, AOM, wait-and-see, antibiotic stewardship (PubMed Search)
As we are approaching the winter in the northern hemisphere, the number of visits for ear pain or respiratory symptoms are expected to increase. The occurrence of acute otitis media (AOM) will also increase, but are these two disease processes related?
Drs. Heikkinen and Chonmaitree published a systematic review of previously reported studies regarding the correlation of these two disease processes (1). As far back as 1990, studies have shown that up to 94% of pediatric patients diagnosed with AOM have concomitant upper respiratory infection (URI) type symptoms at time of diagnosis (2). The viral infections most commonly associated with AOM are respiratory syncytial virus, influenza virus, and adenovirus (3).
The most commonly taught risk factors for developing AOM include young age, male gender, multiple siblings, day care attendance, and passive smoking. These factors are also related to the development of upper respiratory symptoms, and the development of AOM should be thought of as a complication of the upper respiratory infection (4).
Koivunen et al noted the highest incidence of AOM at day 3 after the onset of an URI, and the median time to diagnosis was day 4 (5). If you see a patient in day 2-4 of an URI, who has started to develop an ear effusion, but not clinical AOM, you may want to consider a “Wait-to-see” treatment option if the patient meets treatment criteria (https://em.umaryland.edu/
(1) Heikkinen T, Chonmaitree T. Importance of Respiratory Viruses in Acute Otitis Media. Clinical Microbiology Reviews. 2003;16(2):230-241.
Keywords: GBS, weakness, intubation, CSF, LP (PubMed Search)
Allen JA. Chronic Demyelinating Polyneuropathies. Continuum 2017;23(5):1310–1331
Keywords: pain, extremity (PubMed Search)
A recent article from JAMA (link below) showed that Ibuprofen and opioids are similarly effective in the short term relief of acute extremity pain when used in combination with acetaminophen. The study looked at adults with fractures and sprains and randomized them to one of four groups.
Pain relief was similar in all groups.
With the growing increase in opioid abuse/addiction it is good to know that in our patients that are not allergic to acetaminophen and ibuprofen (or all medications except for that one that begins with a “D”) we can provide good pain relief without using opioids.
Chang AK, Bijur PE, Esses D, Barnaby DP, Baer J. Effect of a Single Dose of Oral Opioid and Nonopioid Analgesics on Acute Extremity Pain in the Emergency Department: A Randomized Clinical Trial. JAMA. 2017 Nov 7;318(17):1661-1667. doi: 10.1001/jama.2017.16190.
Keywords: Marijuana, symptoms, overdose (PubMed Search)
In the US, there are an estimated 22.2 million users of cannabis based on the 2015 National Survey on Drug Use and Health. The incidence of unintentional cannabis ingestion has increased in states that have legalized medical and recreational marijuana. The cited article reviewed of 44 articles involving unintentional cannabis ingestion in children younger than 12 years.
The majority of intoxications were through cannabis resins followed by cookies and joints.
Lethargy was the most common presenting sign followed by ataxia. Tachycardia, mydriasis and hypotonia were also noted. Rarer but more serious presentations included respiratory depression and seizures.
Richards JR, Smith NE, Moulin AK. Unintentional Cannabis Ingestion in Children: A Systemic Review. The Journal of Pediatrics. 2017. Epub ahead of print.
Keywords: Hemodialysis, lithium (PubMed Search)
Lithium salts have been used therapeutically for over a 150 years to sucessfully treat manic depressive symptoms, schizoaffective disorder, and cluster headaches. Lithium has a narrow therapeutic range (0.6-1.5 meq/L) and is 100% eliminated by the kidneys. Multisystem toxicity occurs however CNS toxicity is significant and consist of confusion, lethargy, ataxia, neuromuscular excitability (tremor, fasciculations, myoclonic jerks, hyperreflexia). Since there is a poor relationship between serum concentration and toxicity in the brain, serum blood levels may not reflect extent of toxicity . The goal of enhanced elimination is to prevent irreversible lithium-effectuated neurotoxcity which causes persistant cerebellar dysfunction with prolonged exposure of the CNS to high lithium levels.
Decision for hemodialysis is determined by clinical judgement after considering factors such as lithium concentration, clinical status of patient, pattern of lithium toxicity (acute vs. chronic), concurrent interacting drugs, comorbid illnesses, and kidney function. Strongly consider hemodialysis for the following:
Extracorpeal treatment for Lithoum Poisoning: Systematic Review and Recommendations from the EXTRIP Workgroup. Decker BS, et al. Clin Am Soc Nephrology 2015 Jan
The Syndrome of irreversible lithium-effectuated neurotoxicity. Adityjee, et al. Clin Neuropharmacol. 2005 Jan-Feb;28(1):38-49.
Category: Critical Care
Mechanical Ventilation in Shock
Gidwani H, Gomez H. The crashing patient: hemodynamic collapse. Curr Opin Crit Care 2017; 23:533-540.
Keywords: Shoulder pain, neuritis (PubMed Search)
Parsonage Turner syndrome aka Neuralgic amyotrophy
30 cases per 100,000
Under recognized and often missed
Unknown cause, perhaps post viral. Also reported post stress (surgery, pregnancy)
Can be B/L in 10 to 30%
CC: sudden onset of severe pain in the shoulder.
Can last for hours to weeks.
Radiates to upper arm.
As pain begins to subside, muscle weakness and sensory loss follows.
Can preferentially involve the suprascapular and axillary nerve.
Outpatient workup may include MRI and EMG
Treatment: Supportive. Consider a trial of oral steroids. Provide good pain control.
Majority of patients improve within 3 months. Though up to a third have persistent pain/functional deficit.
Keywords: cardioactive steroids, cardioactive glycoside (PubMed Search)
Many medications are discovered from plants (quinine – cinchona trees) or organisms (penicillin – mold [penicillicum]).
Digoxin was isolated from foxglove (Digitalis lanata), a colorful floral plant often found in many gardens. There are other sources of cardioactive steroids (aka cardiac glycosides) that have similar effect as digoxin.
Non-digoxin cardioactive steroid exposure can result in a positive digoxin level due to cross reactivity. This confirms exposure; however, the “digoxin level” does not represent the true extent of the ingested dose or toxicity.
Non-digoxin cardioactive steroid toxicity
Keywords: aphasia, stroke, middle cerebral artery, MCA, mimic, NIHSS (PubMed Search)
Take Home Point: This small but interesting study looked at the incidence of isolated aphasia presenting for concern of stroke. They found that none of their patients had evidence of an infarct, suggesting that strokes affecting language without motor or sensory deficits are uncommon.
Casella G, Llinas RH, Marsh EB. Isolated aphasia in the emergency department: The likelihood of ischemia is low. Clin Neurol Neurosurg 2017:163:24-26.
Follow me on Twitter @EM_NCC
Category: Critical Care
Keywords: ICU, risk factors, upgrade, decompensation (PubMed Search)
Should that patient be admitted to the floor?
Several studies have evaluated factors associated with upgrade in admitted patients from the floor to an ICU within 24 or 48 hours. Elevated lactate, tachypnea, and "after-hours" admissions have been repeatedly identified as some of the risk factors for decompensation.
Two recent studies tried again to identify predictors of eventual ICU requirement...
Best predictors of subsequent upgrade:
The most common reasons for upgrade:
Effect on mortality?
Despite a more stable initial presentation, mortality of patients who decompensated on the floor (25%) matched that of patients initially admitted to the ICU.
*One of the studies noted that although respiratory rate was demonstrated to be the most important vital sign, it was missing in 42% of the study population, while PCO2 was only obtained in 39% of patients.
Category: Pharmacology & Therapeutics
Keywords: Insulin, Hyperkalemia, Dextrose (PubMed Search)
Strategies for Hyperkalemia Management
Stabilize cardiac membrane
Intracellular movement in skeletal muscles
Patiromer (chronic use only)
Insulin mechanism of action for hyperkalemia:
· Binds to skeletal muscle receptors
· Increased activity of the sodium-potassium adenosine triphosphatase and glucose transporter GLUT4
· Glycemic response occurs at lower levels of insulin
· Potassium transport activity increases as insulin levels increase
Patients with insulin resistance due to type-2 diabetes do not become resistant to the kalemic effects of insulin.
Hypoglycemia following insulin administration for hyperkalemia:
· Occurs 1-3 hours post dose, even with initial bolus of dextrose
· The amount of glucose is insufficient to replace the glucose utilized in response to the administered dose of insulin
· Insulin’s half-life is increased in ESRD leading to longer duration of action
A systematic review of 11 studies regarding insulin dosing for hyperkalemia:
· 22 patients (18%) experienced hypoglycemia
· Studies that only gave 25 grams (1 amp) of dextrose had the highest incidence of hypoglycemia (30%)
· Consider insulin dose reduction in patients with renal failure
· Use an order set to ensure patients receive appropriate POC glucose monitoring to detect delayed onset of hypoglycemia
· Dextrose 50% (25 grams) should be given to all patients with pre-insulin BG <350 mg/dL
Subsequent PRN dextrose 50% (25 grams) should be used to maintain BG >100 mg/dL after insulin administration
1. Sterns RH, Grieff M, Bernstein PL. Treatment of hyperkalemia: something old, something new. Kidney International 2016;89(3):5460554.
2. Harel Z, Kamel KS (2016) Optimal Dose and Method of Administration of Intravenous Insulin in the Management of Emergency Hyperkalemia: A Systematic Review. PLoS ONE 11(5): e0154963. doi:10.1371/journal.pone.0154963
Keywords: elderly, psychiatry, mental health, screening (PubMed Search)
Arias, S. A., Boudreaux, E. D., Segal, D. L., Miller, I., Camargo, C. A. and Betz, M. E. (2017), Disparities in Treatment of Older Adults with Suicide Risk in the Emergency Department. J Am Geriatr Soc, 65: 2272–2277. doi:10.1111/jgs.15011
Category: Critical Care
Core Temp <32 degrees leads to impaired shivering and confers increased risk for malignant ventricular dysrhythmias. Core Temp <28 degrees substantially increases risk of cardiac arrest.
If in cardiac arrest:
If perfusing rhythm:
Consider addition of more invasive rewarming techniques in those with hemodynamic/cadiac instability or without access to VA ECMO/CPB:
Consider stopping resuscitation efforts if/when:
Douglas J. A. Brown, Hermann Brugger, Jeff Boyd, Peter Paal. (2012). Accidental Hypothermia. New England Journal of Medicine. https://doi.org/10.1056/NEJMra1114208
Keywords: Hemodialysis (PubMed Search)
The cornerstone treatment of poisoning is removal of the toxin from the patient. This can be accomplished before absorption into the body by decontamination methods (dermal or gastrointestinal) or after absorption by blocking metabolism of parent compound, displacing drugs from receptors, binding toxins with neutralizing agents (chelators, Fab fragments), or enhancing elimination by dialysis. Toxins that are ideal candidates for dialysis include substances that are low molecular weight, have low volume of distribution (stay in the blood stream), or low protein binding. Toxins most commonly treated with dialysis are:
Keywords: Muscle injury, splinting (PubMed Search)
Mechanism: Blunt trauma to the anterior thigh (frequently football helmet or opponents knee)
Usually involves the anterior quadriceps (rectus femoris and vastus intermedius)
Pain on passive stretch and active contraction
Can develop large hematomas
Loss of knee flexion is a poor prognosticator
Complication: Myositis Ossificans (MO) (5-17%)
Increased risk with delay in treatment > 3 days
Radiographs can lag. Ultrasound in more sensitive
Painful firm area in region of contusion occurring 2 to 3 weeks post injury
Prompt treatment….key to good outcome and earlier return to sports
Large hematoma can be aspirated. NSAIDs may reduce edema and risk of MO. Splinting
Place quadriceps in 120 degrees of flexion for 24 hours following injury (keep muscle lengthened)
Keywords: ARDS, oxygenation index, OI, PALICC, acute lung injury, respiratory distress, PARDS (PubMed Search)
Some pediatric practitioners have adopted the oxygenation index (OI) ([FiO2 × mean airway pressure (Paw) × 100]/ PaO2) or oxygen saturation index (OSI) ([FiO2 × Paw × 100]/ SpO2) to assess hypoxemia in children instead of P/F ratios because of the less standardized approach to positive pressure ventilation in children relative to adults.
OI can be used in pediatric patients to define severity of Acute Respiratory Distress Syndrome (ARDS) in patients receiving invasive mechanical ventilation and assess for potential ECMO treatment.
In contrast, the P/F ratio should be used to diagnose Pediatric ARDS for patients receiving noninvasive continuous positive airway pressure [CPAP] or bilevel positive airway pressure [BiPAP]) with a minimum CPAP of 5 cm H2O.
Oxygen Index (OI) = FiO2 x MAP x 100
Keywords: strychnine (PubMed Search)
Her first book “The mysterious affair at Styles,” Agatha Christie introduced her lead detective in her novels, Hercule Poirot - the Belgian detective. She also described the death of Mrs. Emily Inglethorp by strychnine.
Strychnine is found in a disc-like seed of strychnos nux-vomica, a tree native to tropical Asia and North Australia.
It is currently used as rodenticide (moles and gophers), in Chinese herbal medicine and a traditional remedy in Cambodia.
Strychnine inhibits binding of glycine (a major inhibitory neurotransmitter in spinal cord) to Cl-channel resulting in identical clinical syndrome – seizure-like generalized muscle contraction with normal mental status – as tetanus toxin. Tetanus toxin inhibits the release of presynaptic glycine in the spinal cord.
Goal: decrease muscle hyperactivity
Keywords: weakness, infection, paralysis, intubation, influenza, vaccine (PubMed Search)
It's respiratory infection and flu vaccine season! Time to brush up on Guillain-Barré Syndrome..
- It is the most common cause of acute or subacute flaccid weakness worldwide
- 70% of cases are preceded by an infection in the past 10-14 days, but most are minimized or forgotten by the patient. 40% of these infections are by Campylobacter jejuni.
- 30% develop respiratory failure requiring intubation and ventilation
- Half of the patients will develop their maximum weakness by 2 weeks, most will develop it by 4 weeks.
Donofrio PD. Guillain-Barré Syndrome. Continuum 2017;23(5):1295–1309.
Have your wondered what you should do with patients that you suspect have infectious diarrhea. Well the IDSA has updated their 2001 guidelines for the management of infectious diarrhea. The TAKE HOME Points are:
You can find all the recommendations at https://academic.oup.com/cid/article/doi/10.1093/cid/cix669/4557073/2017-Infectious-Diseases-Society-of-America
Keywords: Vomiting, pediatric, medication (PubMed Search)
Within the first hour after administration, ondosterone, metoclopramide and bromopride were equally efficacious. At the 6 hour and 24 hour period after receiving the initial dose of medication, ondansetron was statistically superior to bromopride (not available in the US) and metoclopramide. There were no reported side effects in the ondansetron group (including diarrhea or sedation).
This was a randomized control trial of children 1 year to 12 years seen in the pediatric emergency department in Brazil for vomiting and given intramuscular bromopride (0.15mg/kg to a maximum of 10 mg), metoclopramide (0.15mg/kg to a maximum of 10 mg), or ondansetron (0.15mg/kg to a maximum of 8 mg). 175 children were included.
Epifanio et al. Bromopride, metoclopramide, or ondansetron for the treatment of vomiting in the emergency in the pediatric emergency department: a randomized control trial. J Pediatr 2017. Article in Press.