UMEM Educational Pearls

Title: Steroids in the Critically Ill

Category: Critical Care

Keywords: Corticosteroids, septic shock, ARDS, acute respiratory distress syndrome, community acquired pneumonia, CAP, dexamethasone, methylprednisolone, hydrocortisone (PubMed Search)

Posted: 7/9/2024 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

This May, the Society of Critical Care Medicine (SCCM) published new recommendations [1] for the use of corticosteroids in critical illness (separate from patients with known adrenal insufficiency or on chronic steroids), namely:

  1. “Suggesting” for all septic shock with continued vasopressor requirement not just “refractory” (requiring 2+ pressors) 
    • Matches the 2021 Surviving Sepsis Campaign Guidelines suggestion [2]
  2. “Suggesting” for ARDS (acute onset, bilateral infiltrates not due to cardiac dysfunction or volume overload, PaO2: FiO2 </= 300)
    • Matches the 2024 American Thoracic Society Clinical Practice Guidelines suggestion [3]
    • Does not explicitly exclude influenza+ ARDS, in which steroids have previously been associated with worsened outcomes [4]
  3. “Recommending” for patients with bacterial community acquired pneumonia and new O2 requirement
    • New guidelines from ATS/IDSA not yet updated from 2019; support primarily from 2023 CAPE COD trial [5]

Bottom Line:

For severe bacterial pneumonia and septic shock, ED physicians should feel comfortable administering a dose of hydrocortisone 50mg IV as hydrocortisone 200mg/day is an accepted regimen for these disease processes. 

For patients with ARDS who remain boarding in the ED, EM docs should discuss initiation of steroids with their intensivists, whether the institutional preference is for dexamethasone 20mg IV (per DEXA-ARDS) [6] or methylprednisolone 1mg/kg/day (per Meduri)[7].

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Title: POCUS for SBO

Category: Ultrasound

Keywords: POCUS, GI, SBO (PubMed Search)

Posted: 7/8/2024 by Alexis Salerno, MD
Click here to contact Alexis Salerno, MD

POCUS has been shown to have a 92.4% sensitive (95% CI 89.0% to 94.7%) and 96.6% specific for identifying SBO. 

Some characteristics of SBO include:

-dilated fluid filled bowel  

-contents of bowel moving to and fro like a washer machine 

-wall thickening and ability to see plicae circulares 

- in high grade obstruction you may also notice intraperitoneal fluid near the dilated bowel. 

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Title: Facial trauma visual diagnosis

Category: Trauma

Keywords: facial trauma, orbit, fracture (PubMed Search)

Posted: 7/7/2024 by Robert Flint, MD (Updated: 4/3/2025)
Click here to contact Robert Flint, MD

Question

Patient struck in left eye. The patient was asked to look up during exam and this is the finding. What imaging modality would you order if so inclined, what is the injury, and what is the disposition/plan? 

Show Answer

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Title: Hip fracture basics

Category: Orthopedics

Keywords: Hip fracture (PubMed Search)

Posted: 7/6/2024 by Robert Flint, MD (Updated: 4/3/2025)
Click here to contact Robert Flint, MD

Shenton's line



Hypokalemia is a common electrolyte abnormality found in pediatric patients. The cut off for low potassium is based on age, with young infants having higher baseline levels of potassium when compared to older children and adults. The most common cause of hypokalemia in children is GI losses (diarrhea), though other considerations include malnutrition, congenital adrenal hyperplasia, renal abnormalities and medication effects. 

Typically, hypokalemia is well tolerated, and the focus of management is based on treating the underlying cause, rather than repleting the potassium. 

Medications should ONLY be initiated in patients who have potassium levels < 3.0 mmol/L OR with those with levels < 3.5 mmol/L with ECG changes. 

In patients receiving treatment, oral potassium administration is typically recommended unless any of the following criteria are met:

  • Potassium level < 2.5 mmol/L
  • Inability to tolerate PO
  • There are any ECG changes concerning for hypokalemia

In these patients IV potassium should be given (typically KCl at 0.5-1mEq/kg/DOSE - Max of 40 mEq/dose). 

Just like in adults, ALL patients require continuous cardiac monitoring when receiving potassium infusions.

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Spontaneous coronary artery dissection (SCAD) occurs when there is an intimal tear that develops within the wall of an epicardial coronary artery, leading to intramural hematoma and false lumen formation with compromised coronary blood flow.  This tear develops in the absence of atherosclerosis, trauma, or iatrogenic injury. SCAD is believed to account for 4% of acute coronary syndromes, and has been found to be the cause of ACS in 35% of women under the age of 50. Women comprise the majority of cases of SCAD( 87-95%). 

Patients with Pregnancy-associated SCAD (P-SCAD) will often present with higher-risk features and more severe presentations compared with non-pregnancy related SCAD. They are more likely to present with STEMI (>>NSTEMI), impaired left ventricular function, left main and multivessel disease, and shock than other cohorts of SCAD patients.

The peak timing of P-SCAD is within the first month postpartum (with the highest incidence within the first week), although cases can occur throughout all trimesters of pregnancy or many months postpartum.

Keep SCAD in your differential for patients without typical risk factors who present with signs/symptoms of ACS. A strong index of suspicion is necessary to prevent bad outcomes and improve morbidity and mortality from this disease entity.

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Noninvasive Ventilation for Preoxygenation

  • Over 1 million critically ill patients are intubated each year in the United States.
  • Hypoxemia can occur in up to 20% of intubations and may lead to adverse outcomes such as peri-intubation cardiovascular collapse or cardiac arrest.
  • Appropriate preoxygenation is critical to increase the safe apnea time and decrease the risk of hypoxemia during rapid sequence intubation (RSI).
  • At present, the majority of critically ill patients undergoing RSI are preoxygenated with an oxygen mask.
  • In a randomized, pragmatic, parallel-group trial conducted in 7 EDs and 15 ICUs in the United States, Gibbs et al compared the use of noninvasive ventilation for preoxygenation to an oxygen mask on the incidence of hypoxemia during intubation.
  • In over 1,300 patients, the incidence of hypoxemia during the interval between induction and 2 minutes after intubation was markedly lower in patients preoxygenated with noninvasive ventilation compared to those preoxygenation with an oxygen mask.
  • Importantly, the greatest benefit to noninvasive ventilation for preoxygenation was seen in patients with acute hypoxemic respiratory failure, those requiring > 70% FiO2 prior to intubation, and those with a BMI > 30.
  • Lastly, the trial did not enroll patients who needed emergent intubation without time for at least 3 minutes of preoxygenation.

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Title: Intranasal ketamine was no better than placebo when used with IV fentanyl for traumatic pain

Category: Trauma

Keywords: Ketamine intranadal fentanyl trauma pain (PubMed Search)

Posted: 6/30/2024 by Robert Flint, MD (Updated: 4/3/2025)
Click here to contact Robert Flint, MD

192 trauma patients who were receiving pre-hospital fentanyl for moderate to severe pain  were randomized to placebo or intranasal 50 mg ketamine as an adjunct for pain control. There was no difference between the two groups in decrease in pain scale. 
The authors concluded: “In our sample, we did not detect an analgesic benefit of adding 50 mg intranasal ketamine to fentanyl in out-of-hospital trauma patients.”

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Needed for sample size determination

Power – (1-beta), where beta is the risk of a type 2 error – rejecting the accepting the null hypothesis when it is true – this is usually selected to be 0.8 or 0.9.

Significance (alpha), the chance of making a type 1 error – accepting the alternate hypothesis when the null hypothesis is true. This is usually selected to be 0.05.

One-tailed or two-tailed – is the null hypothesis one of no difference (experimental arm not better or worse) or one-sided (experimental arm not better)?

Effect Size. This is the challenging part. This is the size of the difference in outcomes you’re looking for. 

  For continuous outcomes (example – difference in pain scores). You’ll need an estimate for the variation in the scores between presentations, or the standard deviation. You can get this from a literature estimate or a from small local measurement, say of 10 patients or so.

  For a dichotomous outcome (example – percentage of successes), you can usually estimate the percentage in one group and choose the difference you are looking for.

The effect size has a big effect on the sample size. Generally, cutting the effect size in half increases the sample size by fourfold.

Statistical software - next pearl.



Prioritizing the timely admission of older patients from the emergency department (ED) to appropriate wards is essential to reduce adverse events, such as falls and infections, and to decrease the duration of hospital stays. Recent cohort studies, both observational and prospective, have demonstrated that elderly patients who experienced prolonged or overnight stays in the ED had a higher in-hospital mortality rate compared to those who were admitted earlier to inpatient care. Efficient patient flow and early admission from the ED to appropriate wards are crucial strategies for improving survival rates and reducing morbidity among older patients.

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The systematic review of presyncope literature found that presyncope should be treated the same as syncope in terms of work up and disposition.

“In conclusion, the prevalence of short-term serious outcomes among ED patients with presyncope ranges from one in four to one in 20, with arrhythmia being the most common serious outcome. Our review indicates that presyncope may carry a similar risk to syncope, and hence, the same level of caution should be exercised for ED presyncope management as that of ED syncope.”

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Title: What is Administrative Harm?

Category: Administration

Keywords: administrative harm, employee, adverse events (PubMed Search)

Posted: 6/26/2024 by Steve Schenkel, MPP, MD (Updated: 4/3/2025)
Click here to contact Steve Schenkel, MPP, MD

“Administrative harm” (defined as “the adverse consequences of administrative decisions within health care”) is a relatively new term for challenges that arise in complex health care work environments. 

41 mostly hospitalists participating in interviews and focus groups found that the concept resonated, and that administrative harms could arise at all levels of leadership, negatively impacted both workforce and patients, were challenging to measure, and pointed to a lack of leadership responsibility and accountability. The group also suggested many approaches and solutions for prevention.

The article is here, https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2820266. If interested, take a look at the thematic tables 2 and 3.

There is a brief editorial comment here, https://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2820275.



Title: Recognizing Sepsis: Man versus Machines

Category: Critical Care

Keywords: sepsis, septic shock, warning scores (PubMed Search)

Posted: 6/25/2024 by Kami Windsor, MD (Updated: 4/3/2025)
Click here to contact Kami Windsor, MD

Background: Sepsis remains a common entity associated with a relatively high rate of inpatient mortality, with timely recognition and treatment being key to improving patient outcomes. Various screening and warning scores have been created to attempt to identify sepsis and those patients at high risk of mortality earlier, but have limited performance because of suboptimal sensitivity and specificity.

A prospective observational study compared the performance of a variety of these scores (SIRS, qSOFA, SOFA, MEWS) as well as a machine learning model (MLM) against ED physician gestalt in diagnosing sepsis within the first 15 minutes of ED arrival. 

  • 2550 patients deemed by EMS or triage nurse as potentially critically-ill
    • Excluded trauma, cardiac arrest, acute MI, stroke activation, patients in labor
  • Seen by ED attendings (94%) / senior residents (6%) at a single urban academic center
    • Visual analog scale assessment, 0-100% likelihood that patient has sepsis
    • VAS >50% treated as ED physician gestalt in favor of sepsis
  • 275 patients ultimately with discharge diagnosis of sepsis present on arrival to hospital
  • Initial VAS outperformed all scores (AUC 0.90; 95% CI 0.88 to 0.92) both at 15 minutes and 1 hour

Although not without its limitations, this study highlights the importance and relative accuracy of physician gestalt in recognizing sepsis, with implications for how to develop future screening tools and limit unnecessary exposure to unnecessary fluids and empiric broad spectrum antibiotics.

Bottom Line: In the era of machine learning models and AI, ED physicians are not obsolete. Even at 15 minutes, without lab results and diagnostics, our assessments lead to appropriate diagnoses and care. In this new normal of prolonged wait times and ED boarding, ED triage and evaluation models that optimize early physician assessment are of the utmost importance.

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Title: STI Prophylaxis

Category: Administration

Keywords: STI, prophylaxis (PubMed Search)

Posted: 6/24/2024 by Visiting Speaker (Updated: 4/3/2025)
Click here to contact Visiting Speaker

Author:

Gabriella Miller (She/Her)

Clinical Instructor

Department of Emergency Medicine

University of Maryland School of Medicine

Doxycycline PEP for the prevention of bacterial STIs.

The CDC now recommends “doxy PEP” for high-risk individuals. Doxycycline post-exposure prophylaxis (doxy PEP) is a prescription for patients to self-administer 200 mg doxycycline by mouth within 72 hours after anal, oral, or vaginal sex to prevent the transmission of chlamydia, gonorrhea, and syphilis. The CDC defines “high-risk” as men who have sex with men (MSM) and transgender women (TGW) who have been diagnosed with a bacterial STI within the past 12 months. They summarize the findings of the French IPERGAY and ANRS DOXYVAC studies, as well as the US DoxyPEP study, which all show promising reductions in risk ratios or hazard ratios of decreasing bacterial STI transmission on high-risk populations, including those who are taking PrEP for HIV. No significant adverse events related to doxy PEP have been reported.

Conclusion:

Counsel patients at high risk for bacterial STIs regarding the prescription of doxy-PEP for patient self-administration within 72 hours after sex.

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Title: AUD treatment options

Category: Pharmacology & Therapeutics

Keywords: alcohol use disorder, phenobarbital, naloxone, treatment (PubMed Search)

Posted: 6/23/2024 by Robert Flint, MD (Updated: 4/3/2025)
Click here to contact Robert Flint, MD

Two recommendations from the recent GRACE 4 publication in Academic Emergency Medicine to consider:

1. Use phenobarbital along with benzodiazepines in patients with moderate to severe alcohol withdrawal. The evidence isn’t robust but is positive when compared to benzos alone.

2. Adults with alcohol use disorder can benefit from anti-craving medications such as naloxone and gabapentin at time of discharge.

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Title: Hip Fractures

Category: Orthopedics

Keywords: hip fracture, transfusion, analgesia (PubMed Search)

Posted: 6/22/2024 by Brian Corwell, MD (Updated: 4/3/2025)
Click here to contact Brian Corwell, MD

Hip Fractures

Femoral neck and intertrochanteric fractures occur most commonly among patients aged 65 and over

Major risk factors for hip fractures include osteoporosis and falls.

Patients with a low body mass index (BMI <22) appear to be at higher risk 

Isolated trochanteric fractures occur more often in young active adults

In-hospital mortality rates are approximately 5% (range 1-10%)  

In addition to making the diagnosis and consulting orthopedic surgery, ED providers must remember to provide adequate analgesia as elderly patients are often under medicated. 

         -Up to 72% receive no prehospital analgesia.

Extracapsular fractures cause more pain than intracapsular fractures due to the greater degree of periosteal trauma. 

Poor pain control predisposes hip fracture patients to delirium

Retrospective studies indicate that patients at higher risk for significant bleeding have at least 2 of the following risk factors:

         Age over 75 years, initial Hgb below 12 g/dL and peri trochanteric fracture location.



Title: Does the height of fever matter in the era of vaccines?

Category: Pediatrics

Keywords: fever, temperature, infection (PubMed Search)

Posted: 6/21/2024 by Jenny Guyther, MD (Updated: 4/3/2025)
Click here to contact Jenny Guyther, MD

Teaching has circulated that a temperature of 40 degrees Celsius or above (hyperpyrexia), was associated with a greater incidence of serious bacterial infection.  However, this teaching originated in a time prior to the availability of childhood vaccinations. In fact, the largest retrospective study to support this used data from 1966-1974.  

2565 WELL APPEARING patients between the ages of 61 days and their 18th birthday who presented to a single tertiary care pediatric emergency department with the chief complaint of fever were included.  The prevalence of serious bacterial infection was compared to the presence of hyperpyrexia, age, chronic conditions, gender and vaccination status.

Serious bacterial infections (SBIs) included: deep space infections, appendicitis, pneumonia, mastoiditis, lymphadenitis, acute bacterial rhinosinusitis, urinary tract infection, pyelonephritis, cholecystitis, tubo-ovarian abscess, septic arthritis, osteomyelitis, bacteremia or bacterial meningitis.

There was NO statistically significant association between hyperpyrexia and SBIs. Older age and make sex were associated with a higher risk of SBIs.

Bottom line: In well appearing children 61 days and older, having a temperature >/= to 40 degrees was not associated with serious bacterial infections.

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Title: Troponin in geriatric fall patients?

Category: Trauma

Keywords: troponin fall geriatric trauma (PubMed Search)

Posted: 6/20/2024 by Robert Flint, MD (Updated: 4/3/2025)
Click here to contact Robert Flint, MD

A prospective European study of patients over age 65 presenting with a ground level fall obtained troponin levels to ascertain if myocardial infarction was a cause of the ground level fall. Troponin levels were elevated in a majority of patients however only 0.5% were defined as having a myocardial infarction. Of the 3% who died within 1 year, troponin was found to be higher than those that survived the one-year study period.  The authors concluded “Our data do not support the opinion that falls may be a common presenting feature of MI. We discourage routine troponin testing in this population. However, hs-cTnT and hs-cTnI were both found to have prognostic properties for mortality prediction up to 1?year.”

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Title: Is prehospital intubation harmful for patients who require a resuscitative thoracotomy?

Category: EMS

Keywords: intubation, timing, trauma arrest, prehospital (PubMed Search)

Posted: 6/19/2024 by Jenny Guyther, MD (Updated: 4/3/2025)
Click here to contact Jenny Guyther, MD

Several studies have shown that patients who require a resuscitative thoracotomy (RT)  have a higher odds of survival if they are transported by police or in private vehicles.  This study examined 195 patients who required RT to see if prehospital intubation and out of hospital time (OOHT) affected ROSC rates.

There was no association between OOHT and ROSC and no association of OOHT and survival.  The mean OOHT for this study was only 25 minutes which is faster than other studies.  

The odds of ROSC were lower in patients who had ANY intubation attempts prior to arrival.

Bottom line: BLS airway management (or supraglottic placement) may be more beneficial for the trauma arrest patient in the prehospital setting.

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Title: Magnesium for RSI?

Category: Critical Care

Keywords: RSI, intubation, magnesium (PubMed Search)

Posted: 6/18/2024 by Mark Sutherland, MD
Click here to contact Mark Sutherland, MD

Magnesium is known to relax smooth muscles.  Interestingly, there is also some literature using it as part of Rapid Sequence Intubation (RSI) pre-treatment in general, in hopes that this or other mechanisms might allow it to improve intubating conditions.  Zouche et al recently published an RCT looking at giving IV magnesium as part of RSI pretreatment in cases where neuromuscular blockade (NMB) is not going to be given (e.g. scenarios where it is contraindicated).  IV Magnesium Sulfate, 50 mg/kg in 100 mL of saline given 15 minutes before induction, significantly improved intubating conditions in those getting sedation but not NMB (95% vs 39%).  

In 2013, Park et al did an RCT giving magnesium to all RSIs, even with the use of rocuronium in those patients, arguing that magnesium is also known to potentiate the effects of non-depolarizing NMB agents.  They also found better intubating conditions in the magnesium patients.

In both trials, magnesium was associated with lower heart rates and less hypertension in the peri-intubation and immediate post-intubation periods (of note: high dose magnesium is known to be associated with lower blood pressures, and can induce overt hypotension).  Neither study was really powered for more important measures like first pass success, mortality, or important side effects like peri-intubation hypotension.

Bottom Line: These are two small trials, and while more abundant literature should probably be obtained before we change our practice, one could consider giving magnesium sulfate, 50 mg/kg in 100 mL saline, prior to intubation in an attempt to improve intubating conditions.  In my opinion, this is probably worth considering in the rare circumstance that your patient has a true contraindication to neuromuscular blockade, but I probably wouldn't start doing this in standard RSI where you're going to be giving NMB until more literature confirms the safety of this approach.  Also, I would avoid this in situations where the patient is already hypotensive or at high risk of peri-intubation hypotension.  This may be worth considering in the very rare patient you're not necessarily going to give NMB to right away (maybe awake fiberoptic intubations?) who are also very low risk for hypotension.

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