UMEM Educational Pearls

Category: Critical Care

Title: HLH in the ED

Posted: 7/20/2021 by Mike Winters, MD (Updated: 12/11/2023)
Click here to contact Mike Winters, MD

Hemophagocytic Lymphohistiocytosis (HLH)

  • HLH is a hematologic disorder that results from overactivation of the immune response (macrophages and cytotoxic T cells).
  • HLH is often underrecognized and has a mortality that can be as high as 75%.
  • Secondary HLH is most commonly associated with infection (sepsis), malignancy (lymphoma), and autoimmune disorders (SLE, RA).
  • Hallmark features of HLH include fever, splenomegaly, hepatomegaly, cytopenias, coagulopathy, elevated ferritin, elevated triglycerides, and decreased fibrinogen levels.
  • ED resuscitation of patients with suspected HLH includes Hematology consultation, treatment of the underlying disorder (infection), and potentially corticosteroids and chemotherapeutic agents.

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Category: Pediatrics

Title: Does atropine prevent bradycardia during rapid sequence intubation in pediatric patients?

Keywords: Bradycardia, intubation, RSI, atropine (PubMed Search)

Posted: 7/16/2021 by Jenny Guyther, MD (Updated: 12/11/2023)
Click here to contact Jenny Guyther, MD

Atropine has historically been used in the pediatric population as a premedication for rapid sequence intubation (RSI) in order to prevent bradycardia.   Recent research indicates that bradycardia that occurs during intubation may be driven by hypoxia as opposed to a vagal response. In 2002, the American Heart Association guidelines recommended pretreatment with atropine for all children younger than 1 year, children receiving succinylcholine, adolescents receiving a second dose of succinylcholine and anyone with bradycardia at the time of induction. The 2015 AHA Pediatric Advanced Life Support guidelines revised the statement on atropine to say that "it may be reasonable for practitioners to use atropine as a premedication in specific emergency intubations when there is higher risk of bradycardia." 
This study retrospectively looked at 62 patients who underwent rapid sequence intubation.  3 patients experienced a bradycardic event during intubation, 1 of which received atropine.  15 patients received atropine for pretreatment. The incidence of bradycardia was similar between those received atropine and those who did not.
Bottom line: Although atropine is generally considered safe, larger studies are needed to determine if there are any specific indications for atropine as a premedication in RSI or if atropine is needed at all for the prevention of bradycardia.

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Category: Orthopedics

Title: NSAIDs for lower back pain (LBP)

Keywords: Lower back pain, NSAIDs (PubMed Search)

Posted: 7/10/2021 by Brian Corwell, MD (Updated: 12/11/2023)
Click here to contact Brian Corwell, MD

NSAIDs for lower back pain (LBP)


NSAIDs are recommended for first line treatment of lower back pain.

Ibuprofen (600mg), ketorolac (10mg) and diclofenac (50mg)  were compared.

3 arm, double-blinded study in an ED population with musculoskeletal LBP.

66 patients in each arm.

Outcomes via telephone interview 5 days later

Primary outcome was improvement in Roland-Morris Disability Questionnaire (RMDQ).

Lower scores indicate better LBP functional outcomes.

Secondary outcomes:  Pain intensity and the presence of stomach irritation.

Baseline characteristics similar in 3 groups.

Results:  No significant differences between 3 arms in primary outcome.

Ibuprofen 9.4, ketorolac 11.9, and diclofenac 10.9 (p = 0.34).

Ketorolac group reported less overall pain intensity at day 5.

Ketorolac group reported less stomach irritation that the other drugs ((p < 0.01).

While there was no differences in terms of functional outcomes, there may be a benefit of using ketorolac in terms of overall pain intensity and stomach irritation. This would benefit from further study in a larger population in order to draw definitive conclusions.


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Category: Toxicology

Title: Pediatric cannabis exposure before and after legalization in Canada

Keywords: cannabis intoxication, trend, Canada, ICU admission, legalization (PubMed Search)

Posted: 7/8/2021 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH


Canada legalized recreational cannabis use in 2017. A retrospective study of children (0-18 years) who presented to pediatric ED with cannabis intoxication/exposure was performed between Jan 1, 2008 to Dec 21, 2019 to assess the trend/severity of intoxication.


  • Single center study: Hospital for Sick Children, Toronto
  • Case identification by ICD 10 code for cannabis intoxication and positive urine drug screening test
  • Pre-legalization period was defined as 1/1/2008 to 4/12/2017
  • Peri-post legalization period was defined as 4/13/2017 to 12/31/2019



A total of 298 patients were identified

  • Pre-legalization period: 232 (77.8%)
  • Peri-post legalization period: 66 (22.1%)
  • Male: 150 (50.3%)
  • Median age: 15.9 years (IQR: 15.0-16.8) 



Peri-post legalization

P value

Monthly ED visit

2.1 (IRQ: 1.9-2.5)

1.7 (IQR: 1.0-3.0)


ICU admission




Respiratory symptoms




Altered mental status




Age < 12 years




Unintentional exposure




Edible ingestion




Respiratory symptoms: tachypnea/bradypnea, cyanosis, O2 sat < 92%, bronchospasm, oxygen requirement

  • Edible ingestion was a predictor of ICU admission (OR: 4.1; 95% CI: 1.2-13.7)



  • Legalization of recreational cannabis in Canada was associated with increased rates of severe intoxication in children.

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Category: Critical Care

Title: Limiting Hands-Off Time in Cardiac Arrest

Keywords: cardiac arrest, CPR, cardiopulmonary resuscitation, hands-off time, CCF, chest compression fraction (PubMed Search)

Posted: 7/6/2021 by Kami Windsor, MD
Click here to contact Kami Windsor, MD


Despite the knowledge that minimizing interruptions in chest compressions during CPR is key to maintaing coronary perfusion pressure and chance of ROSC,1-4 difficulties in limiting hands-off time remain. 

Dewolf et al.5 recently performed a prospective observational study using body cameras to find that 33% (623/1867) of their CPR interruptions were longer than the recommended 10 seconds:

  • 51.6% Rhythm/pulse checks
  • 11.1% Installation/use mechanical CPR device
  •   6.7% Manual CPR provider switch
  •   6.2% ETT placement

Previous studies have shown an increase in hands-off time associated with the use of cardiac POCUS during rhythm checks as well.6,7


Bottom Line:

  • Physicians must be mindful of hands-off time to improve their chance of obtaining ROSC, minimizing each CPR interruption to <10 seconds, and maintaining a hands-on time (also known as chest compression fraction) of >80%. 
  • Change your pulse check to a rhythm check utilizing arterial line placement, end-tidal monitoring, or US/doppler at the femoral artery in order to minimize the search for a pulse as a reason for prolonged CPR interruption.
  • Consider having someone on the team count the seconds out loud during pauses so the entire team is aware of the interruption time and will recognize when CPR needs to be resumed.


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Take-Home Point:
Based on antibiotic resistance and PK/PD data, CDC recommends a single dose of intramuscular ceftriaxone 500 mg for uncomplicated gonococcal infections. Treatment for coinfection with Chlamydia trachomatis is now only recommended if coinfection cannot be excluded. Doxycycline 100 mg BID x 7 days is recommended as treatment for chlamydial coinfection, but adherence should be heavily considered and may preclude the use of doxycycline instead of previously recommended single dose of oral azithromycin 1 g.
• Neisseria gonorrhoeae is the second most commonly reported notifiable sexually transmitted
infection (STI) in the United States
• Treatment of gonococcal infections prevents complications and transmission, but resistance has
developed against several treatment options (i.e., penicillin, fluoroquinolones, cefixime, and
most recently, azithromycin) leading to changes in treatment recommendations over the years

Uncomplicated Gonococcal


2015 Recommendations [1]

2020 Recommendations [2]

Cervical, urethral, rectal, and

pharyngeal infection

Ceftriaxone 250 mg IM x 1 dose, plus azithromycin 1 g PO x 1 dose

Ceftriaxone 500 mg IM x 1 dose

>=150 kg

No recommendation

Ceftriaxone 1 g IM x 1 dose

If coinfection with chlamydia

cannot be excluded

Coverage provided by gonococcal treatment regimen

Add doxycycline 100 mg PO BID x 7 days

Clinical Data:
• Efficacy of ceftriaxone is best predicted by the fraction of time the unbound drug concentration
exceeds the minimum inhibitory concentration (fT>MIC)
• Monte Carlo simulations estimated fT>MIC of 20-24 hours is required for effective urogenital
gonococcal treatment – a 250 mg-dose did not achieve reliable levels for an extended duration,
while a 500 mg-dose did [3]
• In a gonorrhea mouse model, 5 mg/kg (which correlates to 500 mg for an 80-100 kg human) was
the lowest dose 100% effective at eradicating ceftriaxone-susceptible N. gonorrhoeae 48 hours
after treatment, with fT>MIC of 23.6 hours [4]
• Higher intramuscular doses of ceftriaxone are required in order to optimize urogenital
gonococcal eradication
• Practical considerations pose challenges in implementing a protocol for delayed treatment of
chlamydial coinfection pending laboratory confirmation
• If treating for chlamydial coinfection:
o Heavily consider patient adherence to a 7-day course of doxycycline
o If adherence is a concern, treat with 1 gm oral azithromycin
o There are instances (i.e., rectal chlamydia) where doxycycline has demonstrated higher rates of treatment success compared to azithromycin and may be considered as first-line therapy [5,6]
Lauren Groft, PharmD; Infectious Disease Pharmacist

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Category: Critical Care

Title: Hypothermia versus Normothermia after Out-of-Hospital Cardiac Arrest

Keywords: OHCA, hypothermia, normothermia (PubMed Search)

Posted: 6/29/2021 by Quincy Tran, MD (Updated: 12/11/2023)
Click here to contact Quincy Tran, MD

Settings: International multicenter trials; 1:1 randomization, blinded assessment of outcomes.

Patients: adults with witnessed OHCA, regardless of initial rhythm.  Patients had more than 20 minutes of CPR.  Eligible patients were unconscious, not able to follow command, no verbal responses to painful stimuli.

Intervention: hypothermia to target of 33C for 28 hours, then rewarming at rate of 1/3C every hour until  37C.

Comparison: maintaining temperature at 37.5C or less.  Cooling if body temperature reached 37.8C to 37.5C

Outcome: primary outcome was Any cause mortality at 6 months; secondary outcome was poor functional outcome at 6 months (modified Rankin Scale 4-6).

Study Results:

1. 930 hypothermia, mortality 465/925 (50%, RR 1.04, 95%CI 0.94-1.14); 488/881 (55%) had mRS 4-6 (RR 1.0, 95%CI 0.92-1.09).

2. 931 normothermia, mortality 446/925 (48%); 479/866 (55%) had mRS 4-6.

Discussion Points:

  • Hypothermia would lead to higher rates of arrhythmia-related hemodynamic instability.
  • More studies reinforced that preventing fever is beneficial.
  • ED clinicians will not have to rush to cool patients while awaiting for ICU beds (Yay).


Normothermia in coma patients after OHCA did not lead to higher morality or worse neurologic outcomes.

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Category: Orthopedics

Title: Exercise-induced laryngeal obstruction (EILO)

Keywords: Exercise, wheezing, bronchospasm (PubMed Search)

Posted: 6/26/2021 by Brian Corwell, MD (Updated: 12/11/2023)
Click here to contact Brian Corwell, MD

You are covering a sporting event or working an ED shift when a young adolescent athlete without significant PMH presents with SOB and wheezing associated with exercise.

You immediately think exercise-induced asthma, prescribe a short-acting bronchodilator and pat yourself on the back.

While you may be right, there is increasing recognition of an alternative diagnosis

Exercise-induced laryngeal obstruction (EILO)

During high intensity exercise, the larynx can partially close, thereby causing a reduction in normal airflow. This results in the reported symptoms of SOB and wheezing.

This diagnosis has previously been called exercise induced vocal cord dysfunction. As the narrowing most frequently occurs ABOVE the level of the vocal cord, EILO is a more correct term.

While exercise induced bronchoconstriction has a prevalence of 5-20%, EILO is less common with a prevalence of 5-6%.

Patients are typically adolescents, with exercise associated wheezing and SOB, frequently during competitive or very strenuous events. Wheezing is inspiratory and high-pitched. Symptoms are unlikely to be present at time of medical contact unless you are at the event as resolution occurs within 5 minutes though associated cough or throat discomfort can persist after exercise cessation. EIB symptoms typically last up to 30 minutes following exercise.

Inhaler therapy is unlikely to help though some athletes report subjective partial relief. This may be explained as approximately 10% of individuals have both EIB and EILO.

In athletes with respiratory symptoms referred to asthma clinic, EILO was found in 35%.

Consider EILO in athletes with unexplained respiratory symptoms especially in those with ongoing symptoms despite appropriate therapy for EIB.


Category: Pediatrics

Title: Treatment of fingernail avulsion injuries

Keywords: finger injuries, nail bed (PubMed Search)

Posted: 6/18/2021 by Jenny Guyther, MD (Updated: 12/11/2023)
Click here to contact Jenny Guyther, MD

Traditional management (referred to as "operative management") of a nail avulsion is to replace the nail in the epicanthal fold and suture this in place.  A study was done to see if wound cleaning and placement of a non-adhesive dressing was non inferior to this traditional management.  The primary outcome was the appearance of the new nail at 6 months as determined by 2 separate physicians using a Nail Appearance Score (NAS) and who were blinded to the treatment groups.  The secondary outcomes were patient and parental satisfaction and infection rate.  There were no statistically significant differences in the NAS or patient and parental satisfaction scores between the 2 groups.
Parents were informed of both options and allowed to choose between the treatments.  Patients between 1-16 years with proximal or complete nail bed avulsion injuries were included.
Conclusions: In this small study, non-operative management for fingernail avulsions was not inferior to operative management.

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Category: Critical Care

Title: Pan-Scan for OHCA?

Keywords: cardiac arrest, ROSC, computed tomography, CT scan, imaging (PubMed Search)

Posted: 6/16/2021 by Kami Windsor, MD
Click here to contact Kami Windsor, MD


A recent prospective observational study examined the diagnostic usefulness of head-to-pelvis sudden death computed tomography (SDCT) in 104 patients with ROSC and unclear OHCA etiology.

  • Obtained within 6 hours of hospital arrival
  • Noncontrast head CT + ECG-gated chest CTA with abbreviated coronary imaging + contrasted CT of the abdomen to just below the pelvis. 


Diagnostic performance: 

  • Detected 95% of OHCA etiologies diagnosable by CT
  • Detected 98% of time-critical diagnoses requiring emergent intervention (including complications of resuscitation)
  • The sole reason for diagnosis of OHCA etiology in 13%



  • 28% of patients with elevated creatinine at 48h (down from 55% at presentation; study excluded GFR < 30ml/min unless treating provider felt the data was needed for care)
  • 1% (1 patient) required RRT 
  • No false positives noted, no allergic contrast reactions, 1 contrast IV extravasation


Bottom Line: For OHCA without clear etiology, SDCT explicitly including a thoracic CTA may have diagnostic benefit over standard care alone with the added benefit of identification of resuscitation complications. 


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Hand elevation test


  • Hand elevation has been known to reproduce the symptoms of carpal tunnel syndrome.


  • This phenomenon prompted the idea of developing a simple hand elevation test to diagnose carpal tunnel syndrome. 


  • To perform: Ask the patient to elevate both arms in the air for one minute. Hands are raised actively and without strain, keeping the elbows and shoulders relatively loose.


  • A positive test reproduces symptoms of carpal tunnel syndrome. 


  • The hand elevation test has a high sensitivity (75-86%) and specificity (89-98.5%) and may be comparable to or likely better than other provocative tests.

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Category: Neurology

Title: Thrombectomy for Basilar Artery Occlusion?

Keywords: stroke, large vessel occlusion, basilar artery, posterior circulation, thrombectomy (PubMed Search)

Posted: 6/9/2021 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

  • The landscape of acute ischemic stroke treatment changed dramatically with endovascular thrombectomy (EVT).
  • However, few patients with basilar artery occlusions were included in major EVT trials.
  • Basilar artery occlusion accounts for 10% of large vessel occlusions and can result in devastating neurological deficits.
  • The recently published BASICS trial evaluated the efficacy of EVT within 6 hours of symptom onset in 300 patients with basilar artery occlusion strokes.
  • 44.2% of the EVT group had a good outcome compared to 37.7% of the medical treatment group (p=0.19).
    • Good outcome was defined as modified Rankin scale of 0 (no symptoms) to 3 (moderate disability but able to walk without assistance) at 90 days.
    • Symptomatic intracranial hemorrhage was higher in the EVT group (4.5% vs. 0.7%, p=0.06).
    • History of AFib was more common in the EVT group (28.6% vs. 15.1%).
  • It is important to note that this study did not use advanced neuroimaging for patient selection unlike in landmark EVT trials of anterior circulation large vessel occlusion strokes.

Bottom Line: There is no significant difference between endovascular thrombectomy and medical management for basilar artery occlusion strokes within 6 hours of symptom onset. 

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Category: Critical Care

Title: Oral Midodrine Use in Septic Shock

Keywords: midodrine; septic shock; vasopressors; ICU LOS (PubMed Search)

Posted: 6/8/2021 by Kim Boswell, MD
Click here to contact Kim Boswell, MD

A recent pilot study was conducted in two centers (Mayo Clinic & Cleveland Clinic Affiliate) and aimed to evaluate if the administration of oral midodrine in early septic shock could decrease the use of IV vasopressors and decrease ICU and hospital length of stay (LOS).  The study was a placebo-controlled, double blinded randomized trial.

This study enrolled:

  • 32 adult patients 
  • within 24 hours of Sepsis 3 definition who continued to have hypotension (MAP < 70mmHg) after antibiotic & 30mL/kg IVF administration
  • 3 doses of midodrine 10mg were administered

The study did not find a statistical difference between the two groups in the use of vasopressors or ICU/Hospital LOS. However, there was a trend in the midodrine group which is suggestive of decreased vasopressor use and ICU/Hospital LOS. 

It is Important to note the study was not powered to determine clinical significance. Overall the trend noted in the midodrine group should encourage further studies that are clinically powered to determine if there is a statistical difference and therefore a potential benefit to early initiation of oral midodrine in septic shock.


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 Vancomycin infusion reactions can manifest as pruritus and an erythematous rash of the neck, face, and torso during or after a vancomycin infusion.  This is a histamine reaction caused by degranulation of mast cells and basophils, and can be caused short infusion times <60 min.  It is commonly treated with antihistamines and/or a slowing of the infusion rate. 

Historically, this has been called “Red Man Syndrome.”  As we move towards more inclusive language in medicine, it is increasingly necessary to remove language that is insensitive and/or offensive.  Not only is “Red Man Syndrome” offensive towards Native Americans, it also is an inaccurate term that implies a clinical presentation in white male patients when this reaction can occur in any race or gender. 
The preferred terminology is now “vancomycin infusion reaction” or “vancomycin flushing reaction” and is supported by physician, pharmacist, and pediatric professional publications.    
Allergy documentation matters.  Always include descriptors of the reaction to avoid labeling patients “vancomycin allergic” if it truly was an infusion reaction as this can lead to suboptimal second line therapy being unnecessarily selected.  
What you can do:
1.       Replace “Red Man Syndrome” with vancomycin infusion reaction in your teaching and vernacular
2.       Remove “Red Man Syndrome” from patient allergies and replace with Vancomycin Infusion Reaction with a short description of what the patient experienced
3.       Avoid using “Red Man Syndrome” in your future scholarly works and publications

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Category: Critical Care

Title: Early Vasopressin in Septic Shock

Keywords: Pressors, Vasopressin, Sepsis, Septic Shock (PubMed Search)

Posted: 5/31/2021 by Mark Sutherland, MD
Click here to contact Mark Sutherland, MD

Norepinephrine is widely considered the first-line vasopressor for patients in septic shock.  Vasopressin is often added to norepinephrine in patients requiring escalating doses, but when to add vasopressin, and what exactly the benefit is (as opposed to just further titrating up the norepinephrine) remain unclear.  Given the limited evidence for a patient-oriented benefit and the increasing cost of vasopressin, some centers are becoming more judicious in the use of vasopressin.  A systematic review in AJEM October 2021 examined the literature on early (< 6 hours of diagnosis) addition of vasopressin to the management of septic shock patients, compared to either no vasopressin or starting it after 6 hours.

Improved with early vasopressin: Need for renal replacement therapy (RRT; secondary outcome)

No difference: mortality, ICU length of stay, hospital length of stay, new onset arrhythmias


Bottom Line: When, and if, to start vasopressin in patients requiring escalating doses of norepinephrine remains controversial.  Based on the prior VASST trial, many providers will start vasopressin when norepi doses reach ~ 5-15 mcg/min (approx 0.1-0.2 mcg/kg/min), but there remains limited data to support this practice, and either starting vasopressin or continuing to titrate the norepinephrine as needed are both reasonable approaches in most patients.

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What is the mechanism of action of N-acetylcysteine that is used to treat acetaminophen induced liver injury/toxicity?









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Refractory Anaphylaxis

  • Refractory anaphylaxis is defined as anaphylaxis that does not respond to at least 2 doses of 300 mcg of epinephrine given IM into the anterolateral thigh.
  • Refractory anaphylaxis can be due to several factors including patient comorbidities, delayed diagnosis, delayed epinephrine administration, or concomitant beta-blocker or ACE-inhibitor medication use.
  • Consider the following treatments in patients with refractory anaphylaxis, persistent hypotension, and shock:
    • Aggressive IVF resuscitation - patients may need up to 7L of IVFs
    • Epinephrine infusion (1-10 mcg/min) to target a MAP of 65 mm Hg
    • Glucagon (1-5 mg via slow IV push) for those taking a beta-blocker and who fail to respond to epinephrine
    • Norepinephrine, vasopressin, angiotensin II, methylene blue, or dobutamine can be administered with epinephrine for persistent hypotension. 
    • VA-ECMO - though there is no prospective evidence on the use of ECMO in anaphylaxis.

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Category: Pediatrics

Title: Sodium bicarbonate in pediatric cardiac arrests

Keywords: pediatric, cardiac arrest, metabolic acidosis, sodium bicarbonate (PubMed Search)

Posted: 5/21/2021 by Jenny Guyther, MD (Updated: 12/11/2023)
Click here to contact Jenny Guyther, MD

During cardiac arrest, metabolic acidosis develops because of hypoxia-induced anaerobic metabolism and decreased acid excretion caused by inadequate renal perfusion.  Sodium bicarbonate (SB) administration was considered as a buffer therapy to correct metabolic acidosis.  However,  SB has several side effects such as hypernatremia, metabolic alkalosis, hypocalcemia, hypercapnia, impairment of tissue oxygenation, intracellular acidosis, hyperosmolarity, and increased lactate production.  The 2010 Pediatric Advanced Life Support (PALS) guideline stated that routine administration of SB was not recommended for cardiac arrest except in special resuscitation situations, such as hyperkalemia or certain toxidromes.  An evidence update was conducted in the 2020 Pediatric Life Support (PLS) guideline and the recommendations of 2010 remain valid.  This article was a systematic review and meta-analysis of observational studies of pediatric in hospital cardiac arrests.  The primary outcome was the rate of survival to hospital discharge after in hospital cardiac arrests. The secondary outcomes were the 24-hour survival rate and neurological outcomes.   

Bottom line: The result of this study supports current PLS guidelines that “routine administration of SB  is not recommended in pediatric cardiac arrest in the absence of hyperkalemia or sodium channel blocker (eg. tricyclic antidepressant) toxicity”.

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Category: Neurology

Title: Factors that Decrease Post-Lumbar Puncture Headaches

Keywords: Lumbar puncture, LP, post-dural, headache, intracranial hypotension (PubMed Search)

Posted: 5/12/2021 by WanTsu Wendy Chang, MD (Updated: 12/11/2023)
Click here to contact WanTsu Wendy Chang, MD

  • Post-lumbar puncture (LP) headache, reported in up to 33% of patients, is due to a persistent CSF leak causing intracranial hypotension.
  • A recent review by Cognat et al. looked to answer several frequently asked clinical questions:
    • Who is at decreased risk of post-LP headache?
      • Infants and children have a similar prevalence compared to adults.
      • Older patients have a lower risk, with an incidence of <5% in those over 60 years old.
    • Does needle choice minimize the risk of post-LP headache?
      • Atraumatic non-cutting ("Whiteacre" or "Sprotte") needles have lower rates (RR 0.4, 0.34-0.47).
      • The use of atraumatic needles does not affect the rate of success, success on first attempt, or duration of the LP.
    • Does performing the LP in a specific way prevent post-LP headache?
      • LPs performed in the lateral decubitus position and at a higher intervertebral space have a lower incidence.
      • Difficult LPs (e.g. multiple attempts, traumatic tap) do not appear to affect the rate.
      • The volume of CSF removed does not affect the rate.
    • Do any treatments after the LP reduce post-LP headache occurrence?
      • Bed rest after LP does not reduce and may in fact worsen the likelihood.
      • Fluids and caffeine do not prevent post-LP headaches.

Bottom Line: The use of atraumatic needles is most effective in reducing the risk of post-LP headaches. These needles are easy to use and have similar rate of success as cutting needles.

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Category: Critical Care

Title: The RECOVERY Trial: Tocilizumab in COVID-19

Keywords: COVID-19, tocilizumab, ICU, mechanical ventilation (PubMed Search)

Posted: 5/11/2021 by Lindsay Ritter, MD (Updated: 12/11/2023)
Click here to contact Lindsay Ritter, MD


RECAP: RECOVERY trial is a large, randomized, open label, adaptive trial studying different treatments on COVID-19. Most well known is the use of dexamethasone which reduced mortality by 1/3 in COVID patients requiring mechanical ventilation and by 1/5 in those requiring oxygen, with no benefit on those patients not requiring oxygen.

They recently published results in the Lancet on the use of tocilizumab. 


  • Up to 21 days after main randomization, regardless of treatment, RECOVERY trial patients with progressive COVID-19 were eligible for tocilizumab. 


  • April 23rd 2020 to Jan 24th 2021-- 21,550 patients with hypoxia (<92% on RA or requiring O2), systemic inflammation (CRP > 75 mg/L) eligible for standard care or standard care plus toci 400-800 mg (dosing based on weight), second dose 12-24 hours later if no improvement


  • Primary outcome 28 day mortality followed by:
  • Hospital discharge within 28 days
  • Rate of mechanical ventilation 


  • 621 (31%) tocilizumab patients and 729 (35%) of usual care patients died within 21 days (RR 0.85, p=0.0028). Consistent even in those receiving steroids (83%).
  • Tocilizumab group more likely to be discharged from the hospital, less likely to receive invasive mechanical ventilation (35% vs 42%).


  • Tocilizumab improved survival and other clinical outcomes- by 1/3 for those on simple oxygen, and by ½ for those receiving invasive mechanical ventilation.
  • Added to the additional benefit of steroids. 
  • Findings support the earlier REMAP-CAP trial on the effectiveness of tocilizumab for ICU COVID patients 


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