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This pediatric ICU study measured ICP during and after ketamine infusion.  There was no increase in ICP associated with the ketamine infusion. This small study adds to the data that ketamine is safe in pediatric brain injured patients. 

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Question

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"I was kicked in the inside of my knee while it was straight (extended). Look at the x-ray and tell me if its bad"

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For the folks who have been in practice for a while, you may be aware of the roller-coaster evidence base looking at steroids for pneumonia.  Once thought to be beneficial and clearly indicated, of late steroids for pneumonia have fallen out of favor.  Hamad et al have published an excellent (and brief) review in Clinical Infectious Diseases which suggests the pendulum might be swinging back in favor of giving steroids to patients with pneumonia.  It's a ~5 minute read, so I recommend glancing through it yourself, but below are my two cents (solely my opinion) on where we are with steroids for pneumonia.

Take Home Points (OPINION ALERT):

1) When you have a condition present that you consider an indication for steroids (e.g. severe COVID-19 for sure; septic shock, s. pneumo infection, and ARDS depending on how you feel about the existing literature) --> strongly consider giving steroids unless there's a contraindication

2) When you have an undifferentiated patient who MAY have one of these conditions (e.g. pneumonia with COVID pending, patient potentially in ARDS or high risk of going into ARDS, etc) who is very sick --> it is reasonable to give steroids (if no contraindication) or not give steroids.  My tendency is to lean towards giving steroids in these cases, but do be aware that society guidelines recommend against steroids here (although debatable if they just haven't caught up to more recent literature)

3) When you have an undifferentiated patient who may have one of these conditions, but is NOT very sick --> I do not think there is significant enough evidence to support empiric steroids

4) Factors that might push you one way or another:

• Severity of disease (more severe favors giving steroids),
• Pathogen (COVID-19 and s. pneumo favor steroids),
• What formulation of steroids you have availabile.  Some of these studies used continuous hydrocortisone infusions, for example, which most hospitals don't routinely do.
• Comorbidities (uncontrolled diabetes, wound healing issues, risk for opportunistic infections might argue against giving steroids)

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Think before placing a nasogastric tube!

Multiple articles which discussed complications of NGT placement were included in this integrative review, with the majority (n=67) publishing results in English. The authors categorized adverse events into two broad categories:

1) Mechanical adverse events - including respiratory, esophageal, and pharyngeal complications, obstructed tube, intestinal and intracranial (!) perforation, and tube withdrawal 

-The largest cohort (n=44) was respiratory, with displacement or placement of tube to the respiratory tract

2) Others - pressure injury and misconnection

-One study showed pressure related injury in 25%, and 5 articles discussed complications of misconnection (including extravasation of gastric fluids and inadvertent connection to central venous catheters)

16 of the 69 studies reported death as a consequence of improper placement. 

One big takeaway: there is no universally accepted standard for verificaiton of tube placement. Xray is considered to be *most* accurate. Tubes should also be checked periodically and depth should be marked. Evidence-based guidelines need to be developed to improve patient safety, outcomes, and quality of care.

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This systematic review and analysis found in 1822 trauma patients treated with ECMO:

-Overall 66% survival to discharge

-VV ECMO was significantly superior to VA ECMO

-Mean age was 35 years. Typical of ECMO use in trauma is younger healthier patients are chosen to receive ECMO

“ECMO is not a routine life-saving intervention following trauma, but rather a salvage therapy that effectively replaces conventional treatment for young, healthy patients when conventional methods fail. Its complexity requires a multidisciplinary healthcare team and sufficient resources for optimal implementation.”

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Spanish investigators conducted a 6-month, prospective, observational study to determine the impact of emergency department pharmacists on medication errors. They specifically focused on so called "High Alert" medications and on errors that, if undetected prior to administration, were likely to have serious deleterious consequences.

Over the course of the study, the pharmacists reviewed the medication records and histories of nearly 3000 patients. The pharmacists intervened in the care of 557 patients. Errors were most often detected during the process of medication reconcilliation. Over half of the potential errors were considered "severe" and the majority of pharmacist interventions were deemed important to the patient's care. Many of the medication errors detected involved "High Alert" medications.

The Bottom Line: Pharmacists are integral members of a high-functioning emergency department team. Their specialized knowledge contributes to a safe and effective care environment.

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BACKGROUND: Prehospital (EMS) clinicians are positioned on the front lines of health care. With respect to stroke identification and treatment, early recognition is essential to positive outcomes. Considerable variability exists within EMS documentation. Despite considerable variability in documentation, the establishment and tracking of core stroke metrics serves as a benchmark to gauge performance and outline strategies for improvement. 

METHODS: Authors conducted a retrospective, observational analysis of EMS encounters (2018-2019) which ultimately received a diagnosis of an "acute cerebrovascular event." Hospital based diagnoses included: hemorrhagic stroke, ischemic stroke, or transient ischemic attack. The data set was comprised of a statewide EMS documentation and a state wide acute stroke registry. Authors examined compliance with six core performance metrics which included measurement of blood glucose, documentation of last known well time, and on-scene time < 15 mins for patients with suspected stroke. During the 18 month study, almost 6000 encounters met criteria for inclusion. 

RESULTS: EMS documentation remains a significant source of variability. EMS crews were largely compliant with blood glucose measurement. However, last known well time had the lowest (24%) documentation rate. Patients diagnosed with subarachnoid hemorrhage had the lowest rate of compliance with metrics. 

BOTTOM LINE: Accurate prehospital stroke diagnosis remains a challenge. Consistent data collection and benchmarking remains an important first step in the evaluation of performance. Higher NIHSS scores and ischemic strokes are linked to higher rates of metric compliance. 

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Term? Tone? Tantrum?

Immediately after delivery, your initial neonatal assessment should evaluate for:

-       Appearance of full or late pre-term gestation (>34 weeks)

-       Appropriate tone (flexed extremities, not floppy)

-       Good cry and respiratory effort

Newborns meeting this criteria should not require resuscitation. They can be placed skin to skin on mother and allowed to breastfeed. Delayed cord clamping for 60 seconds is recommended, as data shows improved neurodevelopmental outcomes and iron stores in first year of life.

Neonates not meeting these criteria should be brought to the warmer for resuscitation, with the focus being on:

-       Warm - via radiant warmer. Maintain temps 36.5 C – 37.5 C

-       Dry - Neonates have thin skin and lose heat readily from evaporative loses

-       Stim - tactile stimulation on the head, midline of the back and extremities to provoke a cry and encourage respiratory effort

Avoid routinely bulb-suctioning unless there is significant obstructing mucous, as this can increase vagal tone and result in bradycardia. If bulb suctioning is used, first suction the mouth before the nose.

Majority of resuscitations do not require additional support, however if heart rate is <100 or there is poor respiratory effort, the physician should initiate PPV.

PPV settings:   PIP 20              PEEP 5              FiO2 21%         Rate of 60 breaths per minute

Improvement in the neonate’s HR is the primary indicator of effective PPV!

If HR poorly responding (remains <100), ensure appropriate mask size, reposition, suction, and increase PIP (max 35) and FiO2.

If HR drops below 60, intubate with uncuffed ETT

-       Prioritize adequate ventilation as this is the highest priority in neonatal resuscitation

-       Initiate compressions at rate of 120/min.

-       Epi dosing is 0.01-0.03 mg/kg q3-5 min

-       ETT size estimation by gestational age:

        25 weeks = 2.5, 30 weeks = 3.0, 35 weeks = 3.5, 40 weeks = 4.0

IV Fluid Resuscitation

• IVF administration is one of the most common interventions in the resuscitation of critically ill patients.
• The primary goals of IVFs are to augment cardiac output and increase O2 delivery.
• The amount and type of IVF must take into account the patient's pathophysiology and type of shock.
• Sepsis remains one of the most common causes of distributive shock in the ED and ICU.
• Large volumes of IVF in sepsis often do not increase cardiac output and frequently lead to organ congestion.
• Rather than a fixed dose, an individualized approach to IVFs in sepsis based on the patient's history, exam, labs, monitoring, and serial reassessments is likely to lead to better outcomes. 

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This large UK and US study looked at the addition of high dose cryoprecipitate to mass transfusion protocols and found:  “Among patients with trauma and bleeding who required activation of a major hemorrhage protocol, the addition of early and empirical high-dose cryoprecipitate to standard care did not improve all cause 28-day mortality.”

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The objective of a recent study was to analyze the injury and illness characteristics in Iron Man distance triathletes. This information is important for emergency providers who may be asked to directly assist or help coordinate race day medical care.

Intro: The Iron Man distance triathlon is one of the most challenging ultra endurance competitions in the world. 80,000 Iron Man triathletes compete internationally each year to qualify for the Ironman world championship. The race totals 140.6 miles across three legs, beginning with a 2.4 mile swim, followed by a 112 mile cycle, and is completed with a 26.2 mile run.

Retrospective cross-sectional study of medical records from Iron Man distance championship races across a 30-year period (1989-2019). The study population (10,533) consisted of all triathletes treated at mobile medical units along the race route or who presented to the medical tent for evaluation during and immediately after the event.

Mean population age of 37 with a range of 18 to 87 years.

Results: Female athletes were found to present to the medical tent more than males (P < 0.001).

The total incidence of medical encounters by age was found to be higher in both younger athletes (18 to 34 years old) and older athletes (greater than 70 years old) versus middle-aged athletes (35-69 years old) (P < 0.001).

Professional athletes have similar overall medical encounters compared with other athletes.

The busiest hours of the medical tent were between approximately 9 and 14 hours after start time (afternoon and early evening) in which approximately 73% of athletes presented for evaluation and treatment.

Once inside the medical tent 71% of athletes were discharged within an hour and 87% were discharged within 1.5 hours. Athletes were dispatched to the hospital from the medical tent area at a rate of 17.1/1000 athletes (most athletes presenting to the medical tent finished the race and few required hospital transfer).

The most common medical complaints were dehydration and nausea followed by dizziness, exhaustion, muscle cramps, and vomiting.

Blood work was collected for 30% of athletes who entered the medical tent. Of these athletes, hyponatremia was the most prevalent diagnosis and most of whom were symptomatic with symptoms such as confusion, stupor, gait disturbance, muscle weakness, headache, dizziness, fatigue, nausea and vomiting.

Beyond basic medical care, intravenous fluids were the most common medical treatment.

Conclusion: Medical events were more frequent among female athletes as well as both younger and older age categories. Gastrointestinal and exertional related symptoms were the most common complaints in the medical tent. Besides basic medical care, IV infusions were the most common treatment. Most athletes presenting to the medical tent finished the race and only a small percentage were transferred to the hospital.

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This excellent review article discussing damage control resuscitation in traumatically injured children highlights several points including:

-”Damage-control resuscitation (DCR) consists of rapid control of bleeding, avoidance of hemodilution, acidosis, and hypothermia; early empiric balanced transfusions with red blood cells, plasma and platelets, or whole blood when available, and the use of intravenous or mechanical hemostatic adjuncts when indicated.”

-”he 30-day mortality in children with traumatic hemorrhagic shock is estimated to be 36% to 50% compared with the 25% reported mortality in similar adults. The early stages of hemorrhagic shock after injury in children can be more challenging to recognize because of their remarkable compensatory mechanisms. In children unlike adults, blood pressure alone is an insensitive indicator of hemorrhagic shock as hypotension is a late sign often not occurring until blood volume is reduced by >40%.”

-”Based on the current literature, the challenges health care providers must focus on are the early recognition of shock in the pediatric patient, moving the hemostatic resuscitation forward to the prehospital phase when feasible, improvement in times to first blood product, balanced resuscitation and efficiency of massive transfusion protocols (MTPs).”

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The typical bag valve mask ventilator (BVM) for adults has a reservoir volume between 1500-2000 mL depending on the manufacturer while the volume is between 500-1000 mL for a pediatric BVM.  When trying to obtain the recommended tidal volume of 6-8 mL/kg (500-600 mL for the typical adult), one thought was that a pediatric BVM could be used with adult patients so as to avoid iatrogenic barotrauma.  This has been studied on manakins using an oral pharyngeal airway, supraglottic airway and endotracheal tubes (ETT) and has been successful.  This study attempted to obtain the same results in the back of a moving ambulance.  Paramedics and EMTs, squeezing pediatric and adult BVMs with one hand, bagged adult manakins in the back of a moving ambulance (without lights and sirens).  The average tidal volume was recorded using various types of airways (i-gel, King airway and ETT).

Volumes delivered with the pediatric BVM were significantly lower than the tidal volumes with adult BVMs across all airway types suggesting that in the moving ambulance, using pediatric BVMs on an adult patient would not be appropriate.

The I-Gel and King airway provided similar tidal volumes which were not statistically different than volume delivered through the ETT.

EMTs consistently delivered 50% less tidal volumes compared to paramedics. The authors suggested that perhaps the additional training and pathophysiology knowledge that paramedics have could also be important with a skill that is considered basic. 

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Settings: Retrospective study of a national inpatient database (Japan).

Participants:

• All patients who were admitted between April 1, 2018 and March 31, 2021 with a SOFA score > 2 on admission day.
• Propensity score matching using SOFA score at admission was used to group patients according to the first unit of admission. The units of admissions were: ICU, High-dependency unit (HDU, which is also called Intermediate care unit), general ward.

Outcome measurement: Primary outcome was in-hospital mortality, after propensity score matching.

Study Results:

• There were 19770 patients admitted to the IC, 23066 patients in the HDU and 54,234 patients in the ward.
• There were no significant differences in in-hospital mortality among cohorts with SOFA scores of 3–5.
• Patients with SOFA => 6 and admitted to the ICU or HDU were associated with lower mortality than patients with same SOFA score but admitted to the ward (Risk difference -2.3 (95% CI -4.6 to -0.1, P=0.041).
• Patients who had SOFA > 12 and was admitted to the ICU group were associated with significantly lower in-hospital mortality than those with similar SOFA score but was admitted to the HDU (Risk difference -4.3, 95% CI -7.5 to -1.0, P = 0.010)

Discussion:

• Most of the high SOFA scores among ICU patients were due to norepinephrine or mechanical ventilation.
• Patients with SOFA 2-5 and were admitted to the ICU/HDU were associated with higher mortality than those admitted to the ward. This was mostly from patients who needed intensive monitoring, and not support for organ failure.
• ICU admission is also associated with certain adverse events (2).

Conclusion:

Risk-stratifying patients according to SOFA score is a potential strategy for appropriate admission strategies.

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This UK study randomized 90 trauma patients suspected of having major life threatening torso hemorrhage to receive standard resuscitative care vs. standard care plus resuscitative endovascular occlusion of the aorta (REBOA). Mortality was 54% in the REBOA group and 42% in the standard care group. This calls into question the routine use of REBOA in trauma resuscitations.

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Background: It is estimated that nearly 6% of U.S. adults and children report having a food allergy.^1,2 Epinephrine autoinjectors are used to provide life-saving pre-hospital treatment for patients experiencing anaphylaxis in the community, but can have serious consequences if administered incorrectly. Accidental finger-stick injuries with epinephrine auto-injector can result in significant pain and ischemia due to vasoconstriction and decreased blood flow to the digit. Treatments for digital epinephrine injection include supportive care, topical vasodilators, and injectable vasodilators.³

Supportive care^3,4:

• Warm compresses are preferred to increase local blood flow and enhance removal of the drug. Cold compresses may result in worsening ischemia. 
• Apply for 15 minutes every 6 hours

• Increases production of nitric oxide which relaxes smooth muscles and causes vasodilation
• Literature shows variable symptomatic improvement for adults and neonates, but safe use as an adjunct to injectable vasodilators or as monotherapy.
• Apply a 1-inch strip of nitroglycerin 2% ointment over the affected area and repeat every 8 hours until symptoms resolve
• Patients should be monitored for hypotension after application, as topical nitroglycerin is systemically absorbed.

• Alpha-1 adrenergic antagonist that competitively blocks alpha-adrenergic receptors to produce brief antagonism of circulating epinephrine and norepinephrine. Phentolamine also promotes vasodilation and increases capillary blood flow. 
• Evidence for use after accidental injection of epinephrine autoinjector is mostly described in case reports, but one study showed that phentolamine was more effective at vasodilation than either nitroglycerin or sodium nitroprusside for treatment of digital norepinephrine injection. In another study of epinephrine-injected patients, subjects reported normal fingertip sensation in an average of 120 minutes after injection of phentolamine compared to 549 minutes after injection of saline. It took an average of 85 minutes for the epinephrine-injected digits to return to normal color after phentolamine injection compared to an average of 320 minutes after injection with saline.
• Preparation/application: Dilute 5 mg of phentolamine in 10 mL of 0.9% sodium chloride. Inject small amounts subcutaneously into the affected area.

• Beta-2 adrenergic agonist that causes vasodilation and attenuates the effect of alpha adrenoreceptor-mediated vasoconstriction.
• Evidence shows that terbutaline has resulted in immediate and complete resolution of symptoms following accidental digital epinephrine injections if administered within 2 hours of the incident and it may be considered if phentolamine is not available.
• Preparation/application: Dilute 1 mg of terbutaline with 1 mL of 0.9% sodium chloride and inject subcutaneously into the affected area.
• May cause elevations in heart rate and blood pressure, as well as ECG changes. Terbutaline should be used cautiously in patients with cardiovascular disease.

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Diverticular disease is a common condition, with 60% of individuals over age 80 and 30% of those over age 45 (!) having diverticula. Recent estimates show that 10-25% of this subset with suffer at least one episode of acute diverticulitis in their lifetime. Fortunately, the majority of these cases are uncomplicated. This study provides evidence that outpatient treatment of acute diverticulitis is reasonable. 

Study Design:

The DINAMO study was a multicenter randomized open-label non-inferiority trial evaluating the utility of antitbiotics in uncomplicated diverticulitis. The study included adult patients with uncomplicated diverticulitis without significant comorbities. The diagnosis was based on modified Neff classification with patients with a mNeff of 0 being included. Eligible patients were randomized to one of two treatment groups:

1) 600 mg ibuprofen q 8 h alternating with 1000 mg of acetaminophen q 8 h x7 d (Exerimental arm) OR

2) 875/125 mg amoxicillin/clavulanate q 8 h x 7 d in addition to the above (Control arm)

Outcomes of interest and Results: 

Any patients who returned to the hospital underwent repeat CT. Primary of outcome of interest was admission to the hospital on revisit, with secondary outcomes being revisit itself, follow up, pain control, and recovery

There was no statistically significant difference in any of these (for numbers, please refer to article 1 linked below); further, no patients required emergency surgery. 

Implications:

There is a low likelihood ot treatment failure when antibiotics are avoided in acute uncomplicated diverticulitis. This study finds this treatment regimen ot be noninferior to antibiotic treatment in terms of hospital admission, revisit rates, and recovery.  Consider this treatment regimen in eligible patients. 

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