Category: Critical Care
Keywords: CPR, Cardiac Arrest (PubMed Search)
Posted: 11/15/2016 by Rory Spiegel, MD
(Emailed: 6/25/2022)
Click here to contact Rory Spiegel, MD
It is well documented that when left to our own respiratory devices we will consistently over-ventilate patients presenting in cardiac arrest (1). A simple and effective method of preventing these overzealous tendencies is the utilization of a ventilator in place of a BVM. The ventilator is not typically used during cardiac arrest resuscitation because the high peak-pressures generated when chest compressions are being performed cause the ventilator to terminate the breath prior to the delivery of the intended tidal volume. This can easily be overcome by turning the peak-pressure alarm to its maximum setting. A number of studies have demonstrated the feasibility of this technique, most recently a cohort in published in Resuscitation by Chalkias et al (2). The 2010 European Resuscitation Council guidelines recommend a volume control mode at 6-7 mL/kg and 10 breaths/minute (3).
1. Aufderheide TP, Sigurdsson G, Pirrallo RG, Yannopoulos D, McKnite S, von Briesen C, Sparks CW, Conrad CJ, Provo TA, Lurie KG. Hyperventilation-induced hypotension during cardiopulmonary resusci- tation. Circulation. 2004;109:1960 –1965.
2. Chalkias, Athanasios et al. Airway pressure and outcome of out-of-hospital cardiac arrest: A prospective observational study. Resuscitation. November 2016
3. Deakin CD, Nolan JP, Soar J, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation 2010;81:1305–52.
Category: Critical Care
Keywords: amikacin, Torsades de pointes, QT prolongation (PubMed Search)
Posted: 8/20/2019 by Quincy Tran, MD
(Emailed: 6/25/2022)
Click here to contact Quincy Tran, MD
Torsades de pointes and QT prolongation Associated with Antibiotics
Methods
The authors queried the United States FDA Adverse Event Reporting System (FAERS) from 01/01/2015 to 12/31/2017 for reports of Torsade de points/QT prolongation (TdP/QT).
Reporting Odd Ratio (ROR) was calculated as the ratio of the odds of reporting TdP/QTP versus all other ADRs for a given drug, compared with these reporting odds for all other drugs present in FAERS
Results
FAERS contained 2,042,801 reports from January 1, 2015 to December 31, 2017. There were 3,960 TdP/QTP reports from the study period (0.19%).
Macrolides ROR 14 (95% CI 11.8-17.38)
Linezolid ROR 12 (95% CI 8.5-18)
Amikacin ROR 11.8 (5.57-24.97)
Imipenem-cilastatin ROR 6.6 (3.13-13.9)
Fluoroquinolones ROR 5.68 (95% CI 4.78-6.76)
Limitations:
These adverse events are voluntary reports
There might be other confounded by concomitant drugs such as ondansetron, azole anti-fungals, antipsychotics.
Bottom Line:
This study confimed the previously-known antibiotics to be associated with Torsades de pointes and QT prolongation (Macrolides, Linezolid, Imipenem and Fluoroquinolones). However, this study found new association between amikacin and Torsades de pointes/QT prolongation.
Teng C, Walter EA, Gaspar DKS, Obodozie-Ofoegbu OO, Frei CR. Torsades de pointes and QT prolongation Associations with Antibiotics: A Pharmacovigilance Study of the FDA Adverse Event Reporting System. Int J Med Sci. 2019 Jun 10;16(7):1018-1022.
Category: Critical Care
Keywords: Right Ventricle, RV Size (PubMed Search)
Posted: 11/5/2019 by Kim Boswell, MD
(Emailed: 6/25/2022)
Click here to contact Kim Boswell, MD
Rapid Assessment of the RV on Bedside Echo
There are several causes of acute RV dysfunction resulting in a patient presenting to the ER with unstable hemodynamics. Some of these include acute cor pulmonale, acute right sided myocardial infarction and acute submassive or massive pulmonary embolism. While bedside assessment of the LV function is often performed by the ED physician, simultaneous evaluation of the RV can provide crucial information that can help guide therapeutic decisions to prevent worsening of the patient’s clinical condition. A rough guideline to determine RV size and function is below using the apical 4 chamber view.
Normal RV size : <2/3 the size of the LV
Mildly enlarged RV : >2/3 the size of the LV, but not equal in size
Moderately enlarged RV: RV size = LV size
Severely enlarged RV: RV size > LV size
Patients who are found to have RV dilation should be given fluids in a judicious fashion as the RV is not tolerant of fluid overload. Early diagnosis of the cause of acute RV failure should be sought to guide definitive therapy, but early institution of inotropic support should be considered. Frequent reassessments of biventricular function during resuscitation should be performed.
Guidelines for the Echocardiographic Assessment of the Right Heart in Adults: A Report from the American Society of Echocardiography Endorsed by the European Association of Echocardiography, a registered branch of the European Society of Cardiology, and the Canadian Society of Echocardiography, J Am Soc Echocardiogr 2010;23:685-713
Category: Pediatrics
Keywords: hospitalization, RSV, bronchiolitis (PubMed Search)
Posted: 12/17/2021 by Jenny Guyther, MD
(Emailed: 6/25/2022)
(Updated: 6/25/2022)
Click here to contact Jenny Guyther, MD
Willwerth B, Harper M and Greenes D. Identifying Hospitalized Infants Who Have Bronchiolitis and Are at High Risk for Apnea. Annals of Emergency Medicine 48 (4) 2006.
Category: Toxicology
Keywords: hydrofluoric acid, burn, chemical burn, HFA, calcium gluconate (PubMed Search)
Posted: 9/5/2010 by Dan Lemkin, MD, MS
(Emailed: 6/25/2022)
(Updated: 10/2/2010)
Click here to contact Dan Lemkin, MD, MS
Hydrofluoric acid is a weak acid used primarily in industrial applications for glass etching and metal cleaning/plating. It is contained in home rust removers. Although technically a weak acid, it is very dangerous and burns can be subtle in appearance while having severe consequences.
Wilkes G. Hydrofluoric Acid Burns. Jan 28, 2010.
http://emedicine.medscape.com/article/773304-overview
*Extracted from emedicine article.
Wilkes G. Hydrofluoric Acid Burns. Jan 28, 2010.
http://emedicine.medscape.com/article/773304-overview
Category: Visual Diagnosis
Posted: 1/14/2013 by Haney Mallemat, MD
(Emailed: 6/25/2022)
Click here to contact Haney Mallemat, MD
50 year-old male with cough and dyspnea. What's the diagnosis?
Here's your answer: http://www.youtube.com/watch?v=Z4yxqRoKX04&feature=youtu.be
Follow me on Twitter (@criticalcarenow) or Google+ (+criticalcarenow)
Category: Critical Care
Keywords: Ultrasound, Trauma, Pneumothorax (PubMed Search)
Posted: 8/11/2020 by David Gordon, MD
(Emailed: 6/25/2022)
Click here to contact David Gordon, MD
While chest X ray (CXR) is routinely obtained in the setting of traumatic injury, ultrasound (US) is a fast and reliable way to evaluate for life-threatening traumatic injuries requiring emergent intervention, and is supported by the Eastern Association for the Surgery of Trauma (EAST) guidelines. A recent Cochrane Review compared the test characteristics of chest US vs CXR for detection of traumatic pneumothorax when using Chest CT or thoracostomy as the gold standard.
There possible weaknesses of this study, including blinding in the original studies, and several studies may or may not have been at risk for bias as their risk of bias was ‘unclear’. However, the results were consistent across the studies analyzed and remained similar after sensitivity analysis.
Several anatomical as well as patient care issues may confound US findings for pneumothorax such as the presence of bleb, prior thoracic surgery or pathology, as well as main stem intubation.
1. Chan KK, Joo DA, McRae AD, et al. Chest ultrasonography versus supine chest radiography for diagnosis of pneumothorax in trauma patients in the emergency department. The Cochrane Database of Systematic Reviews. 2018;2018(5):CD013031.
2. Mowery NT, Gunter OL, Collier BR, et al. Practice Management Guidelines for Management of Hemothorax and Occult Pneumothorax. Journal of Trauma and Acute Care Surgery. 2011;70(2):510-518.
Category: Pediatrics
Keywords: non-accidental trauma, clavicle fracture, neonate, pediatrics, abuse (PubMed Search)
Posted: 10/4/2014 by Ashley Strobel, MD
(Emailed: 6/25/2022)
Click here to contact Ashley Strobel, MD
Q: What is wrong with this baby? And what Dx should you entertain?
Previously healthy 7d old presents after difficulty feeding, one episode of vomiting and now with intermittent apneic episodes.
Non-accidental trauma (NAT) is most prevalent in children 0-3 months of age.
Radiographically classic metaphyseal lesions, rib fractures, and multiple fractures in various stages of healing are most commonly described in child abuse cases.
How do we know this is not just birth trauma from a shoulder dystocia, LGA (large for gestational age), or difficult vaginal delivery?
The key is dating the fracture. In this recent publication by Walters MM et al, prior to 8 days of life, 100% of radiographs did NOT have callus present. Callus formation is highly unlikely in fractures less than 9 days old, and typically appears by 15 days old. Callus thickness decreases inversely with fracture age. Additionally, subperiosteal new bone formation is highly unlikely in fractures less than 7 days old and typically appears by 10 days old. Subperiosteal new bone formation increases in thickness inversely with fracture age. Therefore, a clavicle fracture in a 7 day old without subperiosteal new bone formation or callus is unlikely from birth trauma and NAT should be considered.
How can you tell if subperiosteal new bone formation is present?
Subperiosteal new bone formation appears as a hazy cortical margin or a thin layer of bone separated from the original cortex by a discrete lucent interval. The new bone increases in thickness with time and may evolve to appear as a lamellated or multilayered linear hyperdensity parallel to the cortex of the bone. See referenced article for great picture examples.
NAT Work-up:
CT head without contrast if ≤2 yo
Skeletal Survey if ≤ 2 yo
AST, ALT, amylase, lipase, CBC, Manual Differential, BMP, UA, Urine Toxicology
Consults: Ophthalmology, Social Work, Child Protection
OH BUTT TUBE (Dark Green Top Sodium Heparin) for further inpatient team studies
ALTE Work-up:
Guided by history, however consider the following:
Full sepsis evaluation for neonate <30 days
ECG
Possible reflux or seizure evaluation
Consider NAT or Pertussis/RSV with cyanosis
It is controversial to send these infants home from the ED. Typically they benefit from 24 hours of monitoring, but this is a pearl for another day.
See article for further pictures of subperiosteal new bone formation:
Walters MM, Forbes PW, Buonomo C, and Kleinman PK. Healing Patterns of Clavicular Birth Injuries as a guide to fracture dating in cases of possible infant abuse. Pediatric Radiology. October 2014; 44: 1224-1229.
@AstrobelMD
Clavicle_Fracture.jpg (1,743 Kb)
Category: Orthopedics
Posted: 10/1/2017 by Brian Corwell, MD
(Emailed: 6/25/2022)
(Updated: 6/25/2022)
Click here to contact Brian Corwell, MD
Category: Orthopedics
Posted: 10/1/2017 by Brian Corwell, MD
(Emailed: 6/25/2022)
(Updated: 6/25/2022)
Click here to contact Brian Corwell, MD