UMEM Educational Pearls

Category: Toxicology

Title: Fomepizole for acetaminophen overdose?

Keywords: acetaminophen overdose, fomepizole, NAC (PubMed Search)

Posted: 7/19/2023 by Natasha Tobarran, DO (Emailed: 7/20/2023) (Updated: 4/22/2024)
Click here to contact Natasha Tobarran, DO

Acetaminophen (APAP) is the leading cause of acute liver failure worldwide. Standard treatment for APAP overdose is with N-acetylcysteine (NAC), which is highly effective if given within 8 hours of ingestion.  However, in delayed presenters or massive ingestions patients can still develop hepatotoxicity. Adjunctive therapies can be considered in these cases including augmented NAC dosing, renal replacement, and fomepizole.

A small amount of APAP is metabolized to N-acetyl-p-benzoquinone imine (NAPQI) by cytochrome 2E1. In therapeutic doses, the body is able to detoxify the NAPQI using glutathione. In overdose, glutathione stores get depleted and NAPQI can cause hepatotoxicity. Mitochondrial damage in APAP overdose is mediated by the c-Jun-N-terminal Kinase (JNK) pathway. 

NAC works to replenish glutathione stores and detoxify NAPQI. In large overdoses, increased dosing of NAC may be necessary. Fomepizole is typically used for its alcohol dehydrogenase inhibitor property to treat methanol and ethylene glycol poisoning. Fomepizole is also a cytochrome 2E1 and JNK inhibitor and can be used in APAP overdose to block the formation of NAPQI and mitigate mitochondrial damage.  Dialysis can be used to eliminate APAP from the body completely in massive overdoses or if significant acidosis or renal failure. 

This study is a case series of 14 patients treated for APAP overdose between 2017 – 2021 at a tertiary hospital

  • Patients treated with standard NAC therapy
  • They also received IV fompeizole loading dose of 15 mg/kg followed by 10mg/kg every 12 hours at the discretion of the treating team
  • Most cases received only the loading dose
  • Some cases also received renal replacement therapies
  • Patients had “better than expected outcomes” based on initial presentation, APAP levels, liver function tests, and expected clinical course
  • No unfavorable outcomes
  • No side effects

Limitations of the study:

  • Patients were treated with NAC which is the standard of care
  • No formal protocol for the administration or identification of patients treated with fompeizole

In summary:

  • NAC is the standard of care in acetaminophen poisonings
  • Consider fomepizole as an adjunctive therapy in patients that are critically ill
  • Consult your poison center 1-800-222-1222 or friendly toxicologist for help in identifying these patients

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Category: EMS

Title: ED handoff of pediatric patients by EMS

Keywords: handoff, communication, adverse outcomes (PubMed Search)

Posted: 7/19/2023 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

Ineffective handoff communications have been shown to occur in up to 80% of medical errors.  Previous studies have shown that up to 1/3 of pertinent information is lost during the handoff of trauma patients.  Interruptions, lack of listening and ED team preoccupation with their own patient assessment have been associated with adverse outcomes.
This study reviewed videotaped footage of pediatric critical care resuscitations and the handoff between the ED and EMS.  Inefficient communication occurred in 87% of handoffs, including 51% of cases with interruptions by staff, 40% with questions from the ED leader about information that had already been given and 65% requesting information that had not yet been communicated.
Bottom line: Allow for an uninterrupted hand off from EMS followed by closed loop communication and asking any additional questions.

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Category: Critical Care

Title: Platelet Transfusion before CVC Placement

Keywords: Central Lines, Platelets, Bleeding (PubMed Search)

Posted: 7/18/2023 by Mark Sutherland, MD (Updated: 4/22/2024)
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Central Venous Catheter (CVC; aka central line) placement is a common procedure in both the ED and ICU, and while overall quite safe, does carry some risk.  In particular, many of us regularly are confronted with the challenge of placing a line in a patient with profound thrombocytopenia, which can result in significant bleeding.  In these cases, should we give platelets before we place the line?

Van Baarle et al published a randomized study in NEJM comparing an empiric 1u platelet transfusion vs no transfusion in patients with a platelet count of 10,000-50,000, prior to line placement.  The study included both HD and non-HD (e.g. TLC) lines, from all three major access sites, in patients in their ICU or hematology ward.  They found statistically fewer serious bleeding events in the transfusion group (4.8%) vs no transfusion group (11.9%).  The study wasn't powered to look at more patient oriented outcomes like mortality, but I'm sure we can all agree less bleeding is probably a good thing.  Also importantly, this study did not evaluate the risks/benefits of delaying line placement to obtain platelets when the line is urgently needed, so I would not recommend extending this to conclude platelets must be given before line placement if the line is needed for something highly time-sensitive (e.g. only available access to infuse pressors in a hypotensive patient).  

 

Bottom Line: It is probably beneficial and appropriate to provide prophylactic platelet transfusion prior to CVC placement in patients with a platelet count less than 50,000, assuming circumstances allow.  

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Category: Trauma

Title: Tme to Access: IO vs IV

Keywords: access, IO, IV, resucitation (PubMed Search)

Posted: 7/9/2023 by Robert Flint, MD (Emailed: 7/16/2023)
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This study found that time to intraosseous was faster than time to peripheral IV. This lead to quicker resuscitation time. This was particularly true in pateints that arrived without a pre-hospital IV. 

 

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Category: Pediatrics

Title: Pediatric fever: Is response to antipyretics enough to discharge?

Keywords: Pediatrics, infectious disease, fever, bacteremia (PubMed Search)

Posted: 7/14/2023 by Kathleen Stephanos, MD (Updated: 4/22/2024)
Click here to contact Kathleen Stephanos, MD

This study attempts to answer the age old question: What is the importance of fever in pediatric illnesses?

The authors' goal was to assess if response to antipyretics was associated with bacteremia. This article retrospectively reviewed 6,319 febrile children in whom blood cultures were sent and found that 3.8% had bacteremia.  They then looked at the fever curve in response to antipyretics for these two groups in the emergency department over 4 hours. The study concluded that patients with bacteremia have a higher rate of persistent fever despite antipyretics. It is important to note the limitations of this study. As this was retrospective, it is unclear what clinical findings resulted in blood cultures being sent - most febrile children did not have any drawn (23,999 were excluded for this reason). They did not assess other vital signs, and did not address other bacterial infections (UTI, cellulitis, meningitis, otitis media, etc).  Additionally, while patients with bacteremia did have a higher likelihood of fever, the majority of patients in both groups had fever resolution within 4 hours, and both groups had some children with persistent fevers. 

Overall, this does seem to support the decision to consider obtaining further testing in those children with a persistent fever, but also emphasizes the importance of not using fever resolution alone as support for discharge to home or exclusion of bacteremia from the differential. 

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Category: Pharmacology & Therapeutics

Title: Optimal calcium repletion for massive transfusion protocol

Keywords: Calcium, Massive transfusion protocol, Citrate, Blood products (PubMed Search)

Posted: 7/13/2023 by Wesley Oliver (Updated: 4/22/2024)
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Citrate is an anticoagulant added to blood products to maintain stability for storage. With the administration of large volumes of blood products, citrate binds to ionized calcium, which can cause hypocalcemia. Evidence for specific calcium administration during massive transfusion protocols is limited; however, a proposed strategy has been to administer calcium gluconate 2 grams for every 2-4 units of red blood cells.

Robinson, et al. performed a retrospective analysis attempting to determine the optimal Citrate:Ca ratio (a novel ratio created for this study) to reduce 30-day mortality. They did not find any differences in mortality; however, they found a Citrate:Ca ratio of 2-3 produced a normalized ionized calcium level with 24 hours of a massive transfusion protocol.

Based on their calculations, this would equate to supplementing 1 g of calcium gluconate for every 3 units of red blood cells given.

***Reminder: Based on the amount of elemental calcium in each gram of calcium gluconate (4.7 mEq) and calcium chloride (13.6 mEq); 3 g calcium gluconate=1 g calcium chloride.***

Bottom Line: Supplementing with calcium gluconate 1 g for every 3 units of red blood cells should be sufficient to maintain normal ionized calcium levels after a massive transfusion protocol.

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Age >36

LOC

Prolonged exposure (>24hrs)

COHgb level >25%

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Category: Trauma

Title: Pelvic Fractures

Keywords: pelvic fracture, binder, hemorrhage (PubMed Search)

Posted: 7/9/2023 by Robert Flint, MD
Click here to contact Robert Flint, MD

Pelvic fractures can be a major source of life threatening hemorrhage. Suspect fracture with significant force/mechanism. Signs are pelvic tenderness (no need to “rock” the pelvis), bruising at perineum, and hypotension in the setting of major trauma. Major classifications of pelvic fractures are lateral compression, anterior posterior (wide public ramus, open book), and vertical sheer (fall from height). An appropriately applied pelvic binding device can be lifesaving. The biggest mistake in applying these devices is to apply them too high. Maximum pressure is achieved with application directly across the greater trochanters.

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Multiple vision disorders may occur after concussion including injury to the systems that control binocular vision including: Convergence insufficiency and Accommodation insufficiency

In order to obtain a single binocular vision, simultaneous movement of both eyes in opposite directions is required.

To look at an object close by such as when reading, the eyes must rotate towards each other (convergence).

Convergence insufficiency is the reduced ability to converge enough for near vision and is a common visual dysfunction seen after concussion.

One of both eyes may also turn outward.

May lead to complaints with reading such as diplopia, blurry vision, eyestrain, and skipping words or losing one's place.

Patient or parent may also report other difficulties such as becoming more easily fatigued when reading, needing to squint and/or having disinterest in reading.

Take home: consider testing convergence in patients with some of these complaints in setting of acute or subacute head trauma.

 

 

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Burns are common pediatric injuries and usually represent preventable unintentional trauma.
Approximately 10% of children hospitalized with burns are victims of abuse. Thermal burns are the most common type of burn and can result from scalding injuries or contact with objects (irons, radiators, or cigarettes). Features of scald burns that are concerning for inflicted trauma include clear lines of demarcation, uniformity of burn depth and characteristic pattern. Abusive contact burns tend to have distinct margins (branding of the hot object), while accidental contact burns tend to have less distinctive edges
How Kids are Different than Adults: 
- Kids have thinner skin, so time to burn/energy required to cause a burn is less. 
- Kids have increased blood volume relative to their mass, so may need more volume resuscitation compared to adults. 
- Kids are more likely to become hypoglycemic so give glucose in mIVF in kids <20 kgs.
- Risk of airway compromise in kids following inhalation injury is higher due to their smaller airway openings 
Treatment:
- Initial treatment should follow ABCs of resuscitation
- Airway: Airway management should include assessment for presence of airway or inhalation injury, with early intubation if such an injury is suspected. Smoke inhalation may be associated with carbon monoxide toxicity; 100% humidified oxygen should be given if hypoxia or inhalation is suspected.
- Circulation: Parkland's formula
     - Fluid requirements = TBSA burned (%) x weight (kg) x4mL
     - Give ½ of total requirements in 1st 8 hours, then give 2nd half over the next 16 hours. 
     - REMEMBER KIDS HAVE BIG HEADS
          - Rule of 9's for adults: 9% for each arm, 18% for each leg, 9% for head, 18% for front torso, 18% for back torso
          - Rule of 9's for children" 9% for each arm, 14% for each leg, 18% for head, 18% for front torso, 18% for back torso. 
Options for pain management
- fentanyl IN
- morphine IV
- ketamine IV
 Burns you should consider admission
- >6% TBSA
- full thickness burns
- specialty areas: face, eyes, airway, genitalia, palmar crease, sole of foot
- concern for non-accidental injury
- caused by treadmill

 

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Category: Toxicology

Title: Pediatric edible cannabis toxicity

Keywords: cannabis exposure, pediatric, toxicity, NPDS (PubMed Search)

Posted: 7/6/2023 by Hong Kim, MD, MPH (Updated: 4/22/2024)
Click here to contact Hong Kim, MD, MPH

Medical Cannabis is permitted in 39 states and Washington DC while 18 sates and Washington DC has legalized recreational cannabis use. As cannabis products become more available, pediatric exposure has also increased.

A retrospective study of National Poison Data System involving children < 6 years from 2017 and 2021 showed: Pre-COVID (2017-2019) & COVID (2020-2021)

  • 7043 exposures: (increase of 1375%)
  • 2017: 207  
  • 2021: 3054 
  • Residential exposure: 97% (n=6842)

Common Clinical effects

  • CNS depression: 70% (n=3381)
    • Pre-COVID: 61.6% --> COVID: 72.9% (p<0.05)
  • Tachycardia: 11.4% (N=548)
    • Pre-COVID: 10.3% -->COVID: 11.6% (p,0.05)
  • Vomiting: 9.5% (n=4827)
    • Pre-COVID: 7.5% -->COVID: 10.0% (p<0.05)
  • Ataxia: 7.4% (n=352)
  • Confusion: 6.1% (n=294)
  • Mydriasis: 5.9% (n=284)
  • Respiratory depression: 3.1%

Disposition

  • Admission: 22.7%
  • Critical care: 8.1% (n=533)
    • Pre-COVID: 6.6% -->COVID: 8.6% (increase of 30%) (p<0.05)
  • Non-critical care: 14.6% (n=1027)
    • Pre-COVID: 9.7% -->COVID: 16.3% (increase of 68%)(p<0.05)

Conclusion

  • Pediatric cannabis exposure has increased between 2017 and 2021. consequently, more pediatrics patients developing toxicity and being hospitalized.

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Category: Gastrointestional

Title: POCUS for Appendicitis

Keywords: POCUS, Appendicitis, Pregnancy (PubMed Search)

Posted: 7/3/2023 by Alexis Salerno, MD
Click here to contact Alexis Salerno, MD

POCUS can be used to screen for appendicitis.

A recent study showed a sensitivity of 66.7% (CI 95% 47.1–82.7), and a specificity of 96.8% (CI 95% 83.3–99.9) during pregnancy, with the highest sensitivity in the first trimester. 

2 methods to locate the appendix are:

1) have your patient point to the area where it hurts the most

2) perform a lawnmower technique over the right lower quadrant looking for the right psoas mucle and the iliac vessels. The appendix will usually be near these structures. 

Sometimes it is easiest to use your curvilinear probe to identify an area of inflammation and then change to the linear probe for better visualization. 

On ultrasound, appendicitis is defined as a non-compressible blind pouch with an outer diameter greater than 6 mm. On short axis the inflammed appendix will look like a target sign:

 

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Category: Trauma

Title: Abnormal pre-hospital SI is a poor predictor even with a normal arrival SI

Keywords: shock index, trauma, pre-hospital (PubMed Search)

Posted: 7/2/2023 by Robert Flint, MD (Updated: 4/22/2024)
Click here to contact Robert Flint, MD

Shock index (heart rate/systolic blood pressure) has been used to predict trauma outcomes. This study from American Journal of Emergency Medicine looked at 89,000 pre-hospital patients who had a normal shock index on arrival at an emergency department. They then looked for those with abnormal pre-hospital shock index vs. those without an abnormal shock index and compared outcomes. Those with an abnormal pre-hospital shock index had worse outcomes than those with normal pre-hospital shock index.

Bottom line: A good handoff from pre-hospital to emergency department staff is critical because any abnormal shock index predicts a worse outcome than those with a normal shock index.

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Category: Ophthamology

Title: Identify this eye exam finding.

Keywords: Optho. (PubMed Search)

Posted: 6/16/2023 by Robert Flint, MD (Emailed: 6/29/2023) (Updated: 6/29/2023)
Click here to contact Robert Flint, MD

Question

 

What is this called? What does it indicate? Treatment?

Show Answer

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Category: Administration

Title: Predictive Rule for Likelihood to Occupy Inpatient Bed

Keywords: predictive rule, EHR, utilization, AI (PubMed Search)

Posted: 6/16/2023 by Robert Flint, MD (Emailed: 6/28/2023) (Updated: 4/22/2024)
Click here to contact Robert Flint, MD

Author- Steve Schenkel, MD MPP Professor of Emergency Mediciner at UMEM:

A recent Annals of Emergency Medicine Publication (here https://www.annemergmed.com/article/S0196-0644(22)01276-8/fulltext) tested a predictive rule for Likelihood to Occupy an Inpatient Bed associated with a common Electronic Health Record.

 

At the individual patient level, the score performed ok. Depending on the chosen threshold, it traded off sensitivity and specificity and generally became more accurate the longer the patient was in the ED.

 

The authors and the associated editorial (here https://www.annemergmed.com/article/S0196-0644(22)01401-9/fulltext) suggest a different, potentially more beneficial use: to allow aggregate prediction of admissions across an entire department and therefore prompt earlier planning to prevent crowding on account of boarding.

 

The takeaway: Administrative prediction rules oriented toward individual patients may be more meaningfully used to predict resource needs, including in-patient beds, across the ED population.

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Settings: Retrospective data from 3 Dutch EDs (development of the score), 2 Denmark ED (for validation of the score). The novel score (International Early Warning Score) will be composed of the National Early Warning Score (NEWS) + Age +Sex

Components of the National Early Warning Score:

  • Respiratory rate,
  • oxygen saturation,
  • supplemental oxygen (yes/no),
  • Temperature,
  • Systolic blood pressure,
  • heart rate,
  • level of consciousness (Alert vs. not).

Participants: All adult patients in the Netherlands Emergency department Evaluation Database (NEED) and Danish Multicenter Cohort (DMC).

Outcome measurement: in-hospital mortality, including death in EDs.

Study Results:

  • 95553 (2314, 2.5% died) patients were used for development of the score, 14809 patients (365, 2.5% died) were in the validation cohort.
  • The IEWS provides higher AUROC (0.87, 95% CI 0.85-0.88) than the NEWS (AUROC 0.82, 95% CI 0.80-0.84) in the validation cohort.
  • The IEWS for the age group 18-65 years (AUROC 0.86, 95% CI 0.80-0.91) had the most improvement, compared to NEWS (AUROC 0.82, 95% CI 0.75-0.89).

Discussion:

  • The study excluded patients whom did not have 2 sets of vital signs, thus, “very sick” or “not sick” patients would be excluded.
  • This novel score was not compared with the updated NEWS2, which incorporates hypercapnia and confusion. Additionally, this novel score was also not compared with another popular score, Modified Early Warning Score (MEWS). Both the NEWS and MEWS scores have been studied extensively in the literature, thus, have been adopted in clinical use.

Conclusion:

This multicenter study showed that IEWS perform better than the NEWS for predicting in-hospital mortality for ED patients.

 

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Category: Orthopedics

Title: Fascia Iliac Block for Hip Fractures

Keywords: POCUS, Hip Fractures, Nerve Blocks, Administration (PubMed Search)

Posted: 6/26/2023 by Alexis Salerno, MD (Updated: 4/22/2024)
Click here to contact Alexis Salerno, MD

The use of a fascia iliaca compartment block has been shown to reduce pain, decrease length of stay and decrease the opiate requirements for patients with hip fractures.  

 

Check out this page on how to perform this procedure.  

 

Fascia iliac blocks can be challenging to implement routinely in the emergency department. Studies show that 2.5% of eligible patients, despite departmental implementation, receive a block.  

 

One recently published article showed that large scale multi-disciplinary implementation can increase the use of fascia iliac blocks. After implementation, the study team found that 54% of eligible patients received a fascia iliac block.  

 

This article is interesting as it provides helpful resources including physician and nursing protocols for performing this block. 

 

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Category: Trauma

Title: Lidocaine use for pain management in rib fracture patients.

Keywords: lidocaine, trauma, rib fractures (PubMed Search)

Posted: 6/25/2023 by Robert Flint, MD (Updated: 4/22/2024)
Click here to contact Robert Flint, MD

Use of intravenous lidocaine has been proposed as an adjunct/replacement for opioids in trauma patients with rib fractures. These small studies show a signal that the use of lidocaine decreased the need for opiate pain medication in this cohort of patients. Larger studies are needed, however, trauma surgeons maybe reaching for intravenous lidocaine in patients they are admitting with rib fractures. Also, transdermal lidocaine patches have been shown to have a similar effect in this patient cohort. “In admitted trauma patients with acute rib fractures not requiring continuous intravenous opiates, lidocaine patch use was associated with a significant decrease in opiate utilization during the patients’ hospital course.” 3

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Category: Administration

Title: How much screen time after concussion?

Keywords: concussion recovery (PubMed Search)

Posted: 6/24/2023 by Brian Corwell, MD (Updated: 4/22/2024)
Click here to contact Brian Corwell, MD

How much screen time after concussion?

Adolescents spent more than 7 hours daily on screen time during the pandemic.

Historically, experts recommended screen time abstinence to various degrees after concussion.

Prior study: RCT of concussion patients (ages 12 to 25) found that those who abstain from screen time for the first 48 hours recovered 4.5 days sooner than those who were permitted screen time.

Population: 633 children and adolescents with acute concussion and 334 with orthopedic injuries aged 8 to 16, recruited from 5 Canadian pediatric emergency departments.

Post concussion symptoms were measured at 7 to 10 days, weekly for three months, and biweekly for three to six months post injury. Screen time was measured.

Results: Screen time was a significant predictor of post concussion symptom recovery with both parent reported somatic and self-reported cognitive symptoms.

There may be an effect of low to moderate screen time (Goldilocks effect) demonstrating that those in the 25th to 50th percentiles had less severe symptoms than those on the higher end of screen time use or those who minimally use of screens!

Low and high screen time were both associated with relatively more severe symptoms in the concussion group compared to the orthopedic injury group during the first 30 days post recovery but not after 30 days.

Conclusion: The association of early screen time with post concussion symptoms is not linear. Recommending moderation in screen time may be the best approach to clinical management.

 Children need to strike a balance between avoiding boredom, deconditioning, isolation, and  overexerting themselves physically or cognitively.

 

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Category: EMS

Title: What are risk factors in ambulance crashes?

Keywords: ambulance, crash, response, fatality, collision (PubMed Search)

Posted: 6/22/2023 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

Between 2010 and 2020, there were 279 fatalities related to ambulance accidents.  In up to 50% of accidents, EMS is not at fault.  The use of lights and sirens and intersections have been previously shown to be the most common risk factor for accidents.  There is a national push for a more judicious use of lights and sirens.  
Most ambulance crashes are minor, but up to 1/3 of crashes can result in significant injury or significant damage to the vehicle.  This study attempted to relate driver demographics and aggressive driving behavior to ambulance crashes using a vehicle telematics system.  The agency in this study responded to about 130,000 calls per year and the incident rate of any crash was 2.1/100,000 miles and the incident rate of a serious crash was 0.63/100,000 miles.  Injuries occured in 8% of the 214 crashes over the 3 year study period.  One third of the cases resulted in significant vehicle damage.  Female sex and age 18-24 were found to be independently associated with a collision.
Bottom line: Transporting patients via ambulance, especially when lights and sirens are used, is not a risk free event.  Even if injuries do not occur, the impact of damage to the vehicle can significantly impact the EMS system.

 

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