UMEM Educational Pearls

This study followed patients presenting to the ED with elevated (SBP>180, DBP>120) blood pressure without evidence of end organ dysfunction for one year.  The patients were followed for major adverse cardiac events. They found: 

“A total of 12,044 patients were enrolled. The prevalence of MACE within one year was 1,865 (15.5%). Older age, male gender, history of cardiovascular disease, cerebrovascular disease, diabetes, smoking, presentation with chest pain, altered mental status, dyspnea, treatment with intravenous and oral hydralazine, and oral metoprolol were independent predictors for one-year MACE. Additionally, discharge with an SBP ?160 mm Hg was not associated with 30-day MACE-free survival after propensity matching (hazard ratio 0.99, 95% confidence interval 0.78–1.25, P?=?0.92).”

Treating to reach a magic number did not help. Most likely, long term control of blood pressure is a more important factor than attempts to lower in the ED.  While this is a high risk group, there is no evidence that acute lowering of blood pressure impacts long term survival.

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Post-Intensive Care Syndrome (PICS) is an increasingly recognized phenomenon of impairment of physical, cognitive, and/or mental health after intensive care admission.  Even more recently, similar deficits in caregivers of patients admitted to the ICU, often called Post-Intensive Care Syndrome Family (PICS-F) is increasingly recognized.  A study recently published by Watland et al in Critical Care Medicine looking at reducing PICS-F through a “caregiver pathway” got me wondering if there's any literature out there about reducing PICS-F via interventions in the emergency department.  Patients' treatment course in the ED is a highly stressful and uncertain time for both the patient and family members, so it stands to reason this is an impactful period where intervention may help, and even in patients where their condition is too advanced for us to make a medical difference, our actions could have a positive impact on long term outcomes for the family members.

The short answer is no, to this author's knowledge and based on my review of the literature, there is no good evidence for reducing PICS-F by ED interventions (hint, hint: if anyone's looking for a good area to study…)  Based on evidence from the critical care realm, the following are probably reasonable approaches that would translate well to the ED:

1. Recognize, especially when you have a patient who likely has a very poor prognosis, that for our critical patients it is important to treat the family, as well as the patient.  
2. Update the family early and often.  Uncertainty is a key contributor to PICS-F.  
3. Consider developing a brochure for family of critically ill patients at your facility.  Basic information such as where to park, how to get into the hospital, where their loved one may go after the ED, where they can get food, what visiting hours are allowed, whom to contact with questions, etc seem exceptionally simple to us but are often early points of stress for family.  
4. Consider screening family members for PICS-F (probably better left to the ICU, but could be considered for longer ED stays or if patient prognosis is extremely poor).  There are multiple validated screening tools available.
5. Consider encouraging patient (if they are able) or family to keep a diary.  ICU diaries have been shown to decrease incidence of both PICS and PICS-F.  See also icu-diary.org
6. If feasible, consider follow up with family members at high risk of PICS-F.  Could be done as a joint venture between the ED and inpatient services or as a hospital-wide initiative.  
7. Engage ancillary services such as pastoral care, palliative care, integrative medicine, and others early and often to foster a multi-disciplinary approach.  Also, make sure to communicate well with your nursing team, who are at the bedside and often more in tune with family signs of future PICS-F.

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This study suggests no. The control arm was given standard physical therapy and the intervention arm was instructed in four basic exercises to do on their own daily for a week. Patents were  then surveyed to assess for long term pain. There was no difference in pain between the two groups. Meaning, at least in this study reliant on patient journaling and follow up, that these four simple exercises did not impact long term pain in chest wall injured patients.  More work needs to be done in this important area.

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In a fascinating perspective piece, Matt Bivens and colleagues explain that the combination of struggle and restraint leads to death not because of hypoxia, but because of acidosis.

The sequence is something like this: exertion or struggle results in an acidotic state -> restraint reduces respiratory ability, especially when held prone or weight is applied to back or chest -> acidosis worsens with the potential for cardiac arrhythmia and arrest.

In this setting, “I can’t breathe” does not mean that there is no air movement over the vocal cords but that respiration is impaired, much as it is in asthma or obstructive lung disease.

Use of sedation in this setting reduces respiration even further, worsening acidosis and risking death. It’s not hypoxia that kills; it’s acidosis.

See the complete perspective here: https://www.nejm.org/doi/full/10.1056/NEJMp2407162.

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A stinger is a short lived neuropraxia to the upper brachial plexus

Named for the temporary sensation that radiates from the shoulder to the hand

Can occur though 3 common mechanisms

Most commonly from direct traumatic or tractional injury

https://www.physio-network.com/wp-content/uploads/2021/11/unnamed-1.png

Common in American Football

Occurs in almost 50% of players over a 4-year college career

          Most commonly to running backs and linebackers in one NFL study

Symptoms:  Unilateral burning pain and tingling in the arm with transient weakness 

Symptoms NOT confined to a single dermatome.

Usually in C5, C6 innervated muscles (deltoid and biceps).

Symptoms are transient usually resolving in approximately 2 minutes

If asked to examine someone for this at a sporting event

Evaluate patient for:

C spine tenderness

Full cervical range of motion

UNILATERAL weakness in shoulder Abductors and external rotators

UNILATERAL weakness in biceps

UNILATERAL weakness in forearm pronation

UNILATERAL weakness in triceps extension

Consider evaluation for concussion symptoms if appropriate

Majority of patients in college and profession sports return to play in game when exam returns to normal

Clinical practice in the world of the Electronic Medical Record has made many a clinician question the value of electronic reminders. 

Banners warn of sepsis, the need for repeat evaluation, vital signs outside expected limits,  wait times, and risks for readmission.

Can they instead help ED flow?

Sayan Dutta and colleagues suggest that they can. When clinicians chose to receive notice of a lab or imaging result, push notification reduced time between final result and ED disposition by 18 minutes (95% CI: 15-21 minutes). 

The likely key here? Clinicians actively chose when and about what to be notified.

See: Result Push Notifications Improve Time to Emergency Department Disposition: A Pragmatic Observational Study, Annals of Emergency Medicine, 85(1), 53-62. https://www.annemergmed.com/article/S0196-0644(24)00404-9/abstract.

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Crowned dens syndrome is an acute inflammatory disease caused by deposition of calcium pyrophosphate dihydrate crystals or hydroxyapatite crystals in the soft tissue  and ligaments surrounding the dense. Patient presentation is severe pain in the neck and base of the skull, low grade fever,  and elevated inflammatory markers. It is most commonly seen in elderly females. Ct scan is the gold standard for diagnosis. Once meningitis and other significant infectious process has been excluded, treatment is anti inflammatory medications including steroids. 

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Infants are typically obligate nasal breathers and the increased mucus production associated with bronchiolitis can impair both breathing and feeding.  AAP bronchiolitis guidelines state that the routine use of deep suctioning may not be beneficial.    

This was an observational study of 121 infants aged 2-23 months with bronchiolitis who received either nasal suction (31), deep suction (68) or a combination (52).  Groups were based on clinician discretion.  Respiratory scores and pulse ox were obtained pre-suction and at 30 and 60 minutes post suction.  

There was no difference between suction type and respiratory score.  However, there was an improvement in respiratory score between the 0-30 and 0-60 time point with any suctioning.  Suction type had no effect on pulse ox, airway adjunct escalation, length of stay or outpatient outcomes.

The study also showed no association between albuterol use and respiratory scores (albuterol is not recommended by the AAP in the management of bronchiolitis).

Bottom line: In this small study, nasal aspiration and deep suction appear to be equal in improving respiratory scores up to 1 hour post suction suggesting that deep suctioning may not be needed.

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Another large database evaluation of the use of etomidate vs. ketamine as an induction agent for intubation found a trend toward higher mortality in the etomidate group. Even when trying to control for steroid use (to control for etomidate’s possible adrenal suppression), etomidate had a higher mortality rate. 
A well done study that adds to the chorus advocating for choosing ketamine when looking for a hemodynamically neutral induction agent.

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This was a review of the cardiac arrest registry of Norway between 2016-2021.  The incidence of pediatric out of hospital cardiac arrests was 4.6 per 100,000 child years and significantly higher in children < 1 year (20.9 per 100,000 child years).  There was an overall 18% one year survival rate in the 308 patients included.  

Leading causes of arrests were choking, respiratory disease, drowning and SIDS, making up 67% of cases.

73% of the arrests were initially asystolic and 14% were PEA on EMS arrival.  The presence of shockable rhythms increased with age and VT/VF were the initial rhythm in up to 15% of the 13-17 year age group.  

88% of patients received bystander CPR ( with 68% receiving both chest compressions and ventilations).  A minority of these patients were in a shockable rhythm, but 7 total patients were in refractory VF.  Mechanical CPR devices were used in 35 patients aged 11-17.  ECMO was started in 19 cases.

Bottom line: The rate of bystander CPR in this study was very high and other jurisdictions can attempt to learn from the system in place in Norway to increase their local prehospital interventions.

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High-Intensity NIPPV for Acute COPD Exacerbations?

• Noninvasive positive pressure ventilation (NIPPV) is frequently used in the management of critically ill patients with an acute COPD exacerbation, and is associated with decreased intubation rates and decreased in-hospital mortality.
• “Low” intensity NIPPV, where the inspiratory positive airway pressure (IPAP) is < 18 cm H2O, is generally used in clinical practice.
• “High” intensity NIPPV, where the IPAP ranges from 20-30 cm H2O has recently been shown to improve gas exchange, ventilatory function, and reduced elevated PaCO2 when compared to low-intensity NIPPV.
• The recently published HAPPEN trial was a randomized trial performed in 30 centers across China and investigated whether high-intensity NIPPV reduced the need for intubation compared with low-intensity NIPPV in patients with an acute COPD exacerbation and hypercapnia.
• In this trial of 300 patients, investigators found that high-intensity NIPPV significantly reduced the number of patients who met criteria for intubation compared with low-intensity NIPPV.
• Importantly, patients were included and randomized in the trial if they remained hypercapnic after initially receiving 6 hours of low-intensity NIPPV.

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In adult patients, ultrasound-guided long catheter IVs for difficult venous access have been shown to provide increased duration of use, reduced complication rates, and greater cost-effectiveness. 

However, there are relatively few studies examining the use of ultrasound for IV access in pediatric patients. 

A recent study, the DIAPEDUS study, investigated the success rate of peripheral IV access with and without ultrasound assistance in pediatric patients with difficult venous access. 

The study included 110 pediatric patients. IVs were placed by 25 nurses and 6 pediatricians, each of whom had completed departmental training involving at least 20 ultrasound-guided IV placements prior to the study. 

The results showed a significantly higher success rate on the first attempt with ultrasound-guided techniques (90% vs. 18%), along with reduced procedural time and fewer attempts overall. 

Bottom Line: For patients with known difficult venous access, ultrasound-guided IV placement should be the first-line approach.

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In this randomized trial of restrictive oxygen (arterial oxygen sat of 94% ) vs. liberal oxygen (12-15 L of O2 per minute) for 8 hours after traumatic injury there was no difference in mortality or major respiratory complications at 30 days between the two groups. 

Further evidence that managing hypoxia is important but over oxygenation at best offers no benefit and may add harm.

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Cardiovascular disease (CVD) is the leading cause of death both in the United States and globally for both men and women.

Major adverse cardiovascular events (MACE) is a commonly used composite outcome.

MACE is defined as non-fatal stroke/acute myocardial infarction/heart failure or cardiovascular death. 

Physical inactivity is a leading risk factor for noncommunicable diseases and death worldwide

              Up to 5 million deaths/yr could be averted with increased physical activity

Regular physical activity reduces the risk of many types of cancer by 8-28%, diabetes by 17%, heart disease and CVA by 19%, and dementia by 20%.

Many adults and children find meeting the recommended physical activity goals very challenging.

A recent observational study found that just 1.5-to-4-minute small bursts of high intensity exercise throughout the day may help lower an individual’s risk of MACE.

To clarify, this does not mean going to the gym to do a 45-minute HIIT class

Vigorous intermittent lifestyle physical activity (VILPA) involves such simple things as carrying the groceries a short distance or taking the work stairs instead of the elevator.

Such activities are more feasible for all of us vs structured exercise for obvious reasons.

Study group was >100,000 middle-aged men and women. Average age 61.

All participants wore an activity tracker continuously for a full week.

This data was used to calculate VILPA bouts throughout the day.

Female participants with no formal exercise regimen who recorded just 3.4 minutes of VILPA a day were 50% less likely to have a MI, had a 67% decreased risk for heart failure and 45% less likely to develop any type of MACE vs those who did not clock any VILPA during their day.

Female participants who recorded just 1.2-1.6 minutes of VILPA a day had a 33% lower risk of MI, 40% decreased risk of heart failure and 30% lower risk of MACE.

In male participants, those with 5.6 minutes of VILPA each day had a 16% reduced risk of having MACE than those who did not have any VILPA. 

              Differences may be due to women’s VILPA intensity was roughly 20% greater than men 

Conclusion: Take the stairs

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Infantile Spasms (now known as Infantile Epileptic Spasms Syndrome- IESS) is a subtle, can't miss diagnosis occurring in children under the age of 2, with 90% presenting before 1 year of age. 

History:

Presentation for these patients can be sporadic, recurrent, flexion or extension of the limbs or head. The patient typically remains alert during an episode, but they can be startled or appear uncomfortable from the sudden movement. 

With smart phone use, parents often have videos of the events that a provider can see as they are often no events in the ED. 

Prognosis is very poor with up to 50% having long-term neuro-cognitive complications or regression. 

Examination:

A complete physical exam should be performed with particular attention to focal neurologic deficits which would require emergent imaging, signs of electrolyte abnormalities (eg. Chvostek's sign in hypocalcemia), and evidence of neurocutenous syndromes (eg. Neurofibromatosis, tuberous sclerosis).

Testing:

Diagnosis is made with EEG showing hypsarrhythmia. This should be done as soon as possible, most often requiring an inpatient admission. 

Lab work can be done to exclude other possible causes of abnormal movements including assessing for electrolyte abnormalities. 

Imaging in the ED is not typically indicated unless there is concern based on exam. MRI is the imaging modality of choice, and is often completed after EEG confirmed diagnosis. 

Treatment:

Management is initiated in conjunction with a pediatric neurologist with most common therapies being corticotropin (ACTH) and vigabatrin.

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A recent review article highlighted the adverse effects that emergency physicians should know of with the novel antineoplastic agents. The adverse effects and the associated agents are briefly summarized from the article in the table below.  A link to the full article is below. 

Link to article: Antibody-Drug Conjugates: The Toxicities and Adverse Effects That Emergency Physicians Must Know - Annals of Emergency Medicine

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The Venous Excess Ultrasound (VExUS) exam integrates IVC, portal, hepatic, and renal vein findings to assess venous congestion and guide management, such as diuresis, in critically ill patients.

Technique:

1. IVC: Measure the IVC diameter. If <2 cm, significant congestion is unlikely, and further assessment is not well validated.
2. Hepatic & Portal Veins: Use a curvilinear probe with color Doppler in the RUQ. The hepatic vein flows away from the probe (blue), and the portal vein, with thicker walls, flows toward the probe (red).
3. Hepatic Vein Doppler: Apply pulse wave Doppler to the hepatic vein or a tributary. If the waveform is not clear, try a different vein.
4. Portal Vein Doppler: After evaluating the hepatic vein, place PW Doppler on the portal vein.

Tips:

• Start from the right upper quadrant, Doppler signals are often easier to obtain and interpret here.
• Delay learning renal vein assessment until comfortable with the other views.
• If the IVC is hard to see subcostally, try a transhepatic view and adjust probe orientation (rotation and fanning).

Interpretation:

• Hepatic Vein: A normal hepatic vein waveform reflects atrial contraction (a wave), atrial filling during ventricular systole (S wave), and atrial filling during early diastole (D wave). As congestion worsens, the proportion of atrial filling during ventricular systole (S wave) decreases and eventually reverses.
• Portal Vein: Normally shows continuous flow. With congestion, it becomes more pulsatile.

Sometimes when other clinical information is contradictory, having the extra data point of the VExUS exam can be extremely useful to determine the best plan for a patient. Practice looking for the portal/hepatic veins and getting the waveforms on patients with a CLEAR clinical picture of venous congestion, then practice on more difficult cases.

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Question

What is the diagnosis? Treatment? Other imaging indicated? 

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This prospective observational study looked at patients with liver lacerations and active contrast extravasation who  either had immediate embolization vs. observation. After matching for age, injury score etc. the observation first approach did as well as those who had immediate embolization.

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This study tried to expand upon what they describe as the classic triad of signs to diagnose ruptured AAA “(1) abdominal pain, (2) hypotension and (3) a pulsatile abdominal mass”.  They tested these against the _modified abdominal aortic aneurysm rupture signs. “_The MARS-signs encompassed (1) the registered pain-associated symptoms or signs, (2) all hypovolemic associated signs, and (3) pulsatile abdominal mass and/or ultrasound finding”. The MARS did slightly better in identifying ruptured AAA retrospectively. For me, this doesn’t add a great deal of help in making this can’t miss diagnosis and further work is necessary.

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