UMEM Educational Pearls

Pneumonia and Sepsis

• As we have discussed, one of the most important components in the ED management of sepsis is the administration of early and appropriate broad-spectrum antibiotics
• Pneumonia remains one of the most common causes of sepsis in the US and worldwide
• Given the steady rise in incidence of MRSA, remember to add vancomycin to your empiric treatment of patients with pneumonia and severe sepsis or septic shock

Feedback as a Teaching Tool

Why do we, in general, stink at giving feedback?

• We were never taught how to do it
• We fear we will hurt someone's feelings
• It's painful to give feedback

Consider a few quick pearls that will increase your success at giving valuable feedback:

• Realize that learners (students/residents) crave feedback....proven in multiple studies
• Feedback IS a powerful teaching tool and isn't just a way of evaluating someone.
• Avoid at all cost, the phrase,"good job." Be specific about what you mean
• Praise in public, perfect in private
• Avoid the "complain syndrome" and don't fall victim to it. This refers to the phenomenon in which we complain about a behavior or trait and NEVER actuall tell the person. We have all done it. Set yourself apart from others by giving the learner the needed feedback.
• Learners won't improve without feedback. Just like the Nike commercial says,"Just do it!"

The elderly are less likely than younger patients to manifest significant (i.e. > 1mm) ST segment elevation on ECG when they have an acute MI. ST depresson and subtle or non-specific changes are more common and should be treated very aggressively. Despite this apparently more benign appearance in the ECGs of elderly patients, they account for 80% of all deaths from acute MI.

FrostBite

Now that we are in the cold winter months, we are more likely to see patient with frostbite and hypothermia.  Here are some tips for treating frostbite.

• Rapidly rewarm the affected body part.  Never attempt rewarming if there is risk of refreezing.
• An appropriate warming technique tub of water at 40-42°C. Higher temperatures should be avoided secondary to the risk of burns. If a tub is not available, use warm wet packs at the same temperature.
• It can take up to 40 minutes for the affected area to thaw.  Thawing is complete when the distal areas flush.
• The only indication for early surgical intervention is debridement of blisters, necrotic tissue or fasciotomy if there is  compartment syndrome.
• It often takes 1-3 months for frostbitten tissue to be declared viable. The affected area generally heals or shrivels and dries up without surgery. Amputation should be delayed as as long as possible. Early surgical consultation for amputation is rarely needed.

Adapted from Frostbite: Treatment and Medication by C. Crawfor Mechem, MD, MS, FACEP as posted on eMedicine.com.

The most common arrhythmias in children presenting to the ED are:

• Sinus tachycardia (50%)
• SVT (13%)
• Bradycardia (6%)
• Atrial Fibrillation (4.6%)

Atrial fibrillation in children is irregularly irregular with disorganized atrial activity with atrial rates ranging from 350-600 BPM. 

Children at increased risk of developing atrial fibrillation include those with underlying structural heart defects and hyperthyroidism.

Hemodynamically stable children have several treatment options including digoxin, amiodarone, propranolol, esmolol, or procainamide for ventricular rate control.

Hemodynamically unstable children need immediate synchronized cardioversion with 0.5 - 1 J/kg.  (don't forget light sedation.)

References:

Sacchetti A, Moyer V, Baricella R, et al. Primary cardiac arrhythmias in children. Pediatr Emerg Care 1999;15:95-98

Doniger S. Pediatric Dysrhythmias. Pediatric Emergency Medicine Reports. Sept 2008. Vol 13, No 9 (This was edited by a UMMS Combined EM/PEDS graduated Dr. Jim Colletti who is Associate Residency Director, Emergency Medicine, Mayo Clinic College of Medicine, Rochester, MN.)

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Below is an edited version of this week's neurological clinical pearl. Somehow the scores and their definitions showed up incorrectly matched.  See corrections below.

 

• Verbal function is one of the three neurologic responses assessed by the Glasgow Coma Scale ( GCS).
• This response is scored on a scale of 1 to 5, 5 being the best response.
  • 5 = Oriented (responds coherently and appropriately to questions such as name, age, situation).
  • 4 = Confused (responds to questions coherently but with some disorientation and confusion).
  • 3 = Inappropriate words (random articulated speech but no conversational exchange).
  • 2 = Incomprehensible sounds (moaning but no words).
  • 1 = No verbal response.

 

BACKGROUND: 

For the first time since its publication, the centers for disease control has dedicated an entire issue of their Morbidity and Mortality Weekly Report to an emergency medical services topic. Vol 55 RR-1 reviews the, "Guidelines for Field Triage of Injured Patients." The report represents a consensus opinion of national experts in EMS, EM, and trauma care. It outlines which patients may be best served via transport to a trauma center.

CRITERION LINKED TO SEVERE INJURY  (Consider transport to nearest TRAUMA CENTER) 

• GCS < 14, SBP < 90 mm Hg, RR < 10 or > 29 per minute (or less than 20 for infants) 
• Penetrating wounds to neck, torso, head
• Flail chest, two or more proximal long bone fractures
• Proximal extremity amputation
• Paralysis
• Open or depressed skull fracture
• Older patients on anticoagulation

From the MMWR: "The National Study on the Costs and Outcomes of Trauma identified a 25% reduction in mortality for severely injured patients who received care at a Level I trauma facility." 

EXTRAS: 

The remainder of the report details the triage decision making process, explains trauma center capabilities, and provides an interesting and detailed review of trauma transport criteria. Link to the current issue is attached.

http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5801a1.htm

 

 

 

 

Octreotide

• Somatostatin-analog that supresses insulin secretion but also treats acromegaly, esophageal varices and secretory diarrhea
• Sulfonylurea-induced hypoglycemia requires frequent monitoring and administration of intravenous dextrose
• Octreotide is considered antidotal therapy since it turns off insulin secretion that is caused by sulfonylureas
• Recent article by Fasano et al Ann Emerg Med 2008 showed that octreotide 75 mcg SQ one-time in the ED was superior to "traditional" therapy with fewer recurrent hypoglycemic episodes during the patient's hospitalization.
• Excellent article worth reading, even if its just the abstract

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Teaching in the Emergency Department

Effective ways to teach in the ED:

• Limit the amount of time you spend teaching (more teaching does not = more learning)....Take Home Point: teach a quick pearl about a case and move on. Dont belabor the point and keep teaching for 5-10 minutes. You will loose the learner.
• Make teaching points applicable to the patient. Theoretical stuff is fine but no one cares about the Krebs cycle or ATP.
• Teach "on the fly" (teach as good teaching moments come up on each case). "Board talks" are nice but are often times not practical in a busy ED.
• Above all, be enthusiastic...without this all teaching will be ineffective

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Clinical Manifestations of Anaphylaxis

• Importantly, manifestations of anaphylaxis occur along a continuum and are dependent upon the type, route, and quantity of antigen exposure.
• Cutaneous (90%), respiratory (40-70%), cardiovascular (30-35%), gastrointestinal (40%), neurologic (10%), ocular, and genitourinary symptoms can all be seen.
• Include anaphylaxis in the differential of any patient with undifferentiated shock, as 10% will not manifest the cutaneous symptoms of urticaria and/or angioedema.

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The use of a glycoprotein 2b/3a receptor antagonist (often inaccurately referred to as a "G2b3a inhibitor") is considered a Class I intervention for patients with unstable angina/non-STE-MI that are going for percutaneous coronary intervention, according to the ACC/AHA 2007 Guidelines.

The exact timing of the initiation of the G2b3aRA is the subject of some debate, but it is certainly worth discussing with your cardiologist consultant/receiving physician whether they want one of these medications initiated in the ED before taking the patient to the cath. lab, and if so which one of these meds they prefer.

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Patient with iritis will typically present with a painful red eye and it can sometimes be difficult to tell if it is due to conjunctivitis or a corneal abrasion.  Some tips that can help differentiate iritis from other causes of painful red are:

1. When pain reduction was used as a diagnostic tool, it had a sensitivity of 80% and a specificity of 86% in determining whether a simple corneal injury was present. In iritis, the pain will NOT be relieved with topical anesthetic.
2. In iritis, injection will be localized predominantly around the iris and not diffusely over the conjunctiva.
3. The consensual light reflex can be used to make the diagnosis. Of course, shining a light in the affected eye will cause pain, but in iritis shining a light in the normal, unaffected eye (by causing consensual movement of the other affected iris) will cause pain if iritis is present.

Finally, ensure you document:

1. Visual Acuity corrected in both eyes.  Use a pinhole if they forgot their glasses.
2. That you flipped their eyelids to make sure that no foreign bodies are lurking under the lids
3. Stain their eyes with flouriscen to ensure there are no corneal abrasions in addition to the iritis.

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Six indications that would lead you to suspect SVT in children:

• history incompatible (no history fever, volume loss, hemorrhage or pain
• P waves absent /abnormal
• HR does not vary with activity
• Abrubt rate changes
• Infants : rate usually >220
• Children : rate usually >180

Remember in the stable child treat withe Adenosine 0.1mg/kg rapid IV push followed by rapid flush.

In the unstable child treat with synchronized cardioversion 0.5 -1 Joules/kg.

Tetrodotoxin - Sodium Channel blocker - Extremely toxic causes paresthesias, dysrhythmias and paralysis - Found in the sushi called Fugu (From the Pufferfish) - Eating the sushi is considered a delicacy and goal is to get just enough of the toxin to get perioral paresthesias after eating. - Also found in the blue-ringed octopus, angelfish and parrot fish. Enjoy your seafood and take a look at the attached pic of actual fugu.

Attachments

• 0901152329_fugu_0111.jpg (145 Kb)

• Eye function is one of the three neurologic responses assessed by the Glasgow Coma Sacle ( GCS).
• This response is scored on a scale of 1 to 4, 4 being the best response.
  • 4 =  Spontaneous eye opening.
  • 3 = Eye opening in response to speech (not to be confused with eye opening in an asleep patient when prompted with speech; these would receive a 4, not a 3).
  • 2 = Eye opening with painful stimuli (i.e. nailbed pressure, supraorbital compression, and/or sternal rub).
  • 1 = No eye opening.

Sepsis and Mechanical Ventilation

• Essential components of the ED management of sepsis include early identification, antibiotics ASAP, fluid resuscitation, and maintaining adequate perfusion pressure.
• If patients continue to have evidence of shock (i.e. high lactate) despite adequate fluids and/or pressors, strongly consider intubation, even in the patient without acute respiratory decompensation.
• The respiratory muscles are avid consumers of oxygen and can use up to 50% of circulating O₂.
• Intubation and paralysis not only increase available O₂ to vital organs, it can also augment cardiac output for patients with persistent septic shock.

Thrombolytic Therapy for Pulmonary Embolism

Indications for administration of fibrinolytic therapy for acute PE:

• Cardiac arrest presumed to be secondary to PE-tPA 50 mg bolus, may be repeated once.
• Massive PE (hemodynamic instability)-arbitrarily defined by BP < 90 mm Hg systolic. Give 10 mg tPA bolus followed by 90 mg over 2 hours. Make sure heparin off during this time frame. tPA is the only FDA approved drug for this but some are starting to use Tenecteplase (single 0.5 mg/kg bolus).
• Submassive PE (normal hemodynamics and evidence of RV strain). This tends to be the most controversial group, although many authorities are now advocating its use. Strongly suspect strain if the Troponin/BNP are elevated and get an ECHO if they are. Most studies that advocate for lytics in this group show significant improvement in PA pressures, RV wall dilatation, etc. What is currently missing is outcome data...i.e. how short of breath and disabled are people with submassive PE at 6, 9, and 12 months? Bottom line, enough evidence exists to support giving to stable patients with RV strain as long as they are carefully screened.
• There is NO evidence that lytics are useful in stable patients without RV strain.
• The administration of thrombolytic therapy for acute PE is within the scope of practice of emergency medicine.

 

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Most clinicians maintain ventilation with 100% oxygen for cardiac arrest patients with return of spontaneous circulation (ROSC). However, there is increasing literature demonstrating that "hyperoxia in the early stages of reperfusion harms postischemic neurons by causing excessive oxidative stress," and this may result in worse neurological outcomes. It is recommended to avoid unnecessary arterial hyperoxia and simply focus on maintaining oxygen saturations in the 94-96% range during the initial post-cardiac arrest period. [Reference: Neumar RW, Nolan J. Post-cardiac arrest syndrome and management. In The Textbook of Emergency Cardiovascular Care and CPR. Lippincott Williams & Wilkins, Philadelphia 2009.]

Conjunctivitis:

Patient presenting to the Emergency Department complaining of "Pink Eye" is very common but how can you be sure that they do not have a bacterial conjunctivitis and absolutely need antibiotics or are they just suffering from a viral or allergic conjunctivitis.

• Bacterial conjunctivitis will typically have  a mucopurulent discharge and the patients will complain that their lids are matted shut in the morning. Though this can occur in allergic or viral conjunctivitis, those with bacterial conjunctivitis typically have a wet, sticky mucopurulent material matted to their lids where viral/allergic conjunctivitis typically have crusting on their lids and lashes due to dried tears and serous secretions.  Bacterial conjunctiviits is also an uncommon condition due to the defense systems of the eye. So most patients can be treated with support care (ie: Warm Compresses).
• Allergic conjunctivitis should affect both eyes.  It would be odd for only one eye to be allergic, so if only one eye is infected that diagnosis is most likely viral or bacterial conjunctivitis.
• When treating allergic conjunctivitis go with the drops.  Several studies have now shown that topical therapy is better than systemic (ie: benadryl, zyrtec, allegra, or claritin) in the resolution of symptoms.

• Burn injuries are common in children and are the 3rd leading cause of unintentional injuries in children age 0 to 18 yrs, only behind MVCs and drowning.
• Burns greater than 20% TBSA require agressive fluid resuscitation. Lactated Ringer's is the most commonly used fluid. 
• Parkland Burn Formula:  LR over 24 hours = 4mlxkgx %BSA burned. 1st half over 1st 8 hours, 2nd half over subsequent 16 hours.  Add maintenance fluids to this amount for patients < 30 kg.
• Urine output is the best way to assess adequate fluid resuscitation.  Place a foley and goal output is 1-2 ml/kg/hr in children.  (0.5 to 1 ml/kg/hr in adults)
• Oligoanalgesia is very common in pediatric patients.  Use morphine 0.1 mg/kg IV/IM or Oxycodone 0.1 mg/kg po.
• 6% of burned children < 12 years old are victims of abuse.  So keep a high index of suspicion in children with burns. 

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