UMEM Educational Pearls

Category: Misc

Title: PICO for Research Question

Keywords: Research Question (PubMed Search)

Posted: 5/20/2024 by Michael Witting, MD
Click here to contact Michael Witting, MD

Starting a study? Frame your research question in the PICO format:

Patients (consider severity of presentation, setting, demographics)

Intervention (either something you propose or something in use)

Comparison (another group, the same group without intervention, or a benchmark)

Outcome (a measurement)

This classic format has been used to evaluate studies, as in Journal Club (by our esteemed Dr. Wilkerson), as a literature search tool, or by the Cochrane review. 

Starting with a PICO research question can help you narrow your focus and maintain it.

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Category: Trauma

Title: Vasopressors in hemorrhagic shock

Keywords: vasopressor, hemorrhage, shock, trauma (PubMed Search)

Posted: 5/19/2024 by Robert Flint, MD (Updated: 6/17/2024)
Click here to contact Robert Flint, MD

In this podcast, the concept of vasopressor use in hemorrhagic shock is discussed.  Key take away points:

  1. US and UK literature is much less supportive of vasopressor use in hemorrhagic shock than continental European literature.
  2. Concept is while filling the tank with blood, getting some squeeze in the venous system to keep it circulating.
  3. If a young trauma patient has cool extremities, they are already vasogenic and unlikely to benefit from vasopressors. Warm extremities mean they may benefit from vasopressors.
  4. Norepinephrine is the drug of  choice. Aim for a maintenance dose of 3-5 mcg/min and no need to titrate because you are not looking for arterial constriction, just venous tone.
  5. Low dose Vasopressin drip may be beneficial as well, however more literature is needed. 
  6. Blood is still the answer in these patients! Vasopressors are an adjunct to creating a balanced resuscitation.

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Category: Pediatrics

Title: Seasonality of pediatric visits for suicidality

Keywords: psych, pediatric mental health, suicide (PubMed Search)

Posted: 5/17/2024 by Jennifer Guyther, MD (Updated: 6/17/2024)
Click here to contact Jennifer Guyther, MD

This was a cross sectional study examining insurance data to determine if there is seasonality related to ED visits and psychiatric hospitalizations related to suicidality.

Suicidality includes both suicidal ideation and suicide attempts (but not suicide).  One survey showed that up to 12% of US adolescents reported serious thoughts of suicide.  This study included 73,123 patients where 19.4% were direct inpatient admissions and 80.6% were ED visits, 44% of whom were subsequently admitted.

Metrics for suicidality in 10-18 year olds peaked in April and October with a nadir in June.  Incidentally, in the Spring of 2020 when US schools closed due to COVID, there was a decrease in both ED visits and hospitalizations with April and May having the lowest rates across the study period.

School is believed to increase stress with risk factors such as bullying and peer pressure, academic and extracurricular stressors and poor sleep hygiene.

Bottom line: There has been an increase in adolescent suicidality over the recent years, many of whom present to the ED for evaluation.  More mental health resources are needed, especially during the school year.

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Category: EMS

Title: Prehospital obstetric events

Keywords: delivery, neonatal, OB, contractions (PubMed Search)

Posted: 5/15/2024 by Jennifer Guyther, MD (Updated: 6/17/2024)
Click here to contact Jennifer Guyther, MD

Maternal morbidity continues to increase in the US with a mortality rate in 2021 of 39.2 deaths/100,000 live births.  There has been an intense focus on training and quality improvement within hospitals, but not much has changed in the prehospital education arena.  This study aimed to quantify the complications encountered by EMS clinicians.  

In the 2018-2019 EMS dataset used, there were a total of 56,735,977 EMS activations which included 8641 out of hospital deliveries, 1712 documented delivery complications and 5749 records of newborns.

1% of the out of hospital deliveries had a documented complication for the mother.  Of these complications, 94% were for hemorrhage, 6% for abnormal presentation, 0.2% for shoulder dystocia, and 0.4% for nuchal cord.  

Few patients had medications given, including 0.4% receiving oxytocin.  no patients received prehospital blood transfusion or TXA.  Of note, in the years since this data was obtained, TXA and whole blood have started to appear on more medic units, but it is still not necessarily commonplace.

Bottom line: While still rare, prehospital delivery does occur and EMS should be prepared for any possible complications.  Medical directors should look at their jurisdictional/state protocols to see if oxytocin/TXA or whole blood should be included (if not already available).  EMS clinicians should be educated on up to date management of OB emergencies.

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This retrospective study looked at patients diagnosed with urinary tract infections receiving an IV dose of antibiotics  prior to discharge and compared ED length of stay and return visit rate. They found:

“Parenteral antibiotic administration in the ED was associated with a 60-minute increase in ED LOS compared with those who received an oral antibiotic (P < 0.001) and a 30-minute increase in ED LOS compared with no antibiotic (P < 0.001). No differences were observed in revisits to the ED at 72 hours”

Appears no benefit to the practice of IV antibiotics prior to discharge in UTI patients.

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Category: Trauma

Title: Brain Injury Associated Shock

Posted: 5/12/2024 by Robert Flint, MD (Updated: 6/17/2024)
Click here to contact Robert Flint, MD

Hemodynamic instability in trauma patients is most often associated with hemorrhagic shock, however, there is an entity known as brain injury associated shock (BIAS). BIAS is thought to be associated with catecholamine surges secondary to brain injury.  BIAS is found in both isolated head injury pts as well as multi-trauma patients. Studies have identified BIAS in 13% of adult  trauma patients and up to 40% of pediatric major trauma patients.  
We know hypotension in brain injury worsens outcome.  We should assume hemorrhagic etiology until we prove otherwise. Once we suspect BIAS and have excluded hemorrhagic etiology our strategy should switch to  blood pressure support using non-blood product management.

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Concussion Visits to the Emergency Department

In a study looking at concussion discharge instructions in the ED:

  • Physician documented discussion of concussion discharge instructions occurred in 41% 
  • Printed discharge instructions were given 71% of the time
    • This was more likely to occur with 
      • Kids > adults 
      • Sport > non-sport related concussions
  • Appropriate discharge instructions 75%
  • Cognitive rest recommendations 12%
  • Referrals to sports concussion specialist 43%
    • Note referral should generally occur with ongoing symptoms lasting one month or greater.

A 2020 study looked at patients aged 6-18 years diagnosed with concussion on either first or subsequent ED visit.

Those patients with delayed diagnosis required more medical visits during recovery, had a significantly longer time to symptom resolution (21 vs. 11 days), and had a higher likelihood of having persistent concussion symptoms.

Take home: Consider printed concussion discharge instructions in the appropriate ED patients as this has downstream benefits for health and recovery.

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Intranasal medications are an increasingly popular option for pediatric patients, particularly for analgesia and anxiolysis, with an increasing number of medications being used via the intranasal route of administration. 

Fentanyl has been shown in prior studies to be a safe and effective pain management strategy for children, but is likely under utilized. In sickle cell patients, studies have shown that time to analgesia may improve outcomes including hospitalization. 

In 2023, Rees et al. showed that in the sickle cell patient population IN fentanyl can be a very effective tool for patient's experiencing a Vaso-occlusive episode (VOE). This study looked at 400 children with a mean age of 14.6 years. Of these 19% received IN fentanyl.

Ultimately, the IN fentanyl patient population had a shorter time to initial administration of analgesia and a lower chance of admission to the hospital. 

Notably, this was not a randomized study, so there is limitations in assessment of the causality of the lower discharge rates. However this is a tool that could likely be used more regularly in the pediatric sickle cell patient population to allow for more rapid pain management in the emergency department.

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Category: Pharmacology & Therapeutics

Title: Medications to Avoid in Myasthenia Gravis

Keywords: myasthenia gravis, myasthenic crisis, exacerbation, drugs to avoid (PubMed Search)

Posted: 5/9/2024 by Alicia Pycraft
Click here to contact Alicia Pycraft

Myasthenia gravis (MG) is an autoimmune neuromuscular disorder that affects an estimated 14 to 20 patients per 100,000 in the United States. Most patients with MG have autoantibodies against acetylcholine receptors (AChRs), which disrupt neuromuscular transmission through downregulation, destruction, blocking of AChRs or disrupting receptors in the postsynaptic membrane.

Several medications may worsen MG or precipitate myasthenic crisis, however, incidence is difficult to describe as literature is largely limited to case reports and there is often presence of other confounding factors. There are two proposed mechanisms for medications to cause or exacerbate MG:

  1. Eliciting an autoimmune reaction against neuromuscular junction 
  2. Interference with neuromuscular transmission

Several medications commonly used in the emergency department are known to impair neuromuscular transmission and may induce or worsen MG. The following medications should be avoided, or used with extreme caution in patients with MG*: 

*This list contains several common medications utilized in the emergency department, but is not an all-inclusive list of medications that may exacerbate MG. Please refer to the reference section for additional information.

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Oftentimes, CT imaging is used in diagnosis of emergent abdominal pathology. However, there may be instances where there is hesitancy to use IV contrast, whether due to patient factors or extrinsic factors (remember the contrast shortage during covid?) 

This study examines the diagnostic accuracy of dry CT. 3 quaternary centers with residency training programs participated, and contrasted images underwent further processing to remove any IV or oral contrast. Both residents and faculty reviewed the images, and findings were compared to both the initial read by radiologist as well as independent reads by a panel of experts. They looked for both primary findings (those that explained the abdominal pain) as well as actionable secondary findings (ie incidental findings requiring additional imaging or further management).

When compared to contasted imaging, the accuracy of dry CT was 70% (faculty, 68% to 74%; residents, 69% to 70%). Faculty had higher accuracy than residents for primary diagnoses but lower accuracy for actionable secondary diagnoses. 

Thus when considering the necessity of contrast, please consider the potential for missed diagnosis.

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Category: Trauma

Title: Blunt Cardiac Injury

Keywords: trauma, blunt, cardiac injury, shock, thoracic (PubMed Search)

Posted: 5/5/2024 by Robert Flint, MD
Click here to contact Robert Flint, MD

Blunt Cardiac Injury is a continuum from asymptomatic, not clinically relevant to catastrophic, life ending disease . Consider blunt cardiac injury in patients with significant force to the chest wall or sudden deceleration injuries (motor vehicle crashes, motorcycle crashes, falls from height etc.). This algorithm is helpful when working up patients suspected of having significant blunt cardiac injury. 

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BACKGROUND:
Prehospital administration of whole blood involves some areas of controversy. Though theoretical benefits are clear, concerns about logistics and timing of blood often dominates the discussion. This study was a retrospective analysis of prehospital blood administration within an urban EMS system from 2021-2023. Primary endpoints included: time to administration and in hospital mortality. 

PATIENTS/METHODS:
The study population included patients presenting to the EMS system with signs and symptoms of hemorrhagic shock (SBP<70 or SBP<90 + HR> 100, n=61) and who received at least 1 unit of prehospital blood (PHB).  The EMS system administered blood in conjunction with an advanced resuscitative bundle (calcium, TXA, blood). Isolated head injuries and blunt trauma patients were excluded from the analysis.  The control group (n=82) was comprised of patients in the system's trauma registry presenting to EMS PRIOR to the initiation of whole blood and who exhibited similar clinical crtieria. 

RESULTS:

  • PHB patients had significantly higher BP upon arrival to hospital
  • Following multivariate regression analysis, each minute delay to blood administration was linked to an independent increase in mortality of 11%
  • PHB group demonstrated lower in hospital mortality 
  • PHB group linked to longer prehospital time interval (increased scene times) 

BOTTOM LINE:
In this prospective study conducted within an urban EMS system, patients receiving prehospital whole blood demonstrated improved vital signs and reduced mortality when compared to a control group. Slightly extended prehospital time intervals for patients receiving PHB may be offset by the measured benefits of whole blood therapy.

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Category: Obstetrics & Gynecology

Title: Postpartum Depression

Keywords: postpartum depression (PubMed Search)

Posted: 5/2/2024 by Michele Callahan, MD (Updated: 6/17/2024)
Click here to contact Michele Callahan, MD

Perinatal mental health problems are unfortunately quite common: according to the World Health Organization, approximately 10% of women in high-income countries and approximately 30% in low- or middle-income countries are affected.

It's important to be able to distinguish “baby blues” from more significant mental health issues. Typical symptoms of the “baby blues” include mild and short-lived changes in mood, as well as feelings of exhaustion, worry, and unhappiness in the weeks that follow giving birth.

Symptoms that are more severe or lasting >2 weeks post-partum should prompt further investigation and discussion with a mental health professional. Symptoms of perinatal depression may include: feeling persistently sad, feelings of hopelessness, loss of interest or pleasure in hobbies/activities, trouble bonding with the infant, appetite changes, and can even become as severe as wanting to harm onself or one's child. There are specific DSM-5 Criteria used to diagnose postpartum depression.

Universal screening for all pregnant and postpartum patients is highly recommended, and can be life-saving.

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Title: Safety and Efficacy of Reduced-Dose Versus Full-Dose Alteplase for Acute Pulmonary Embolism: A Multicenter Observational Comparative Effectiveness Study

Settings: Retrospective observational study from a combination of Abbott Northwestern Hospital and 15 others as part of the Mayo Health system.

Participants: Patients between 2012 – 2020 who were treated for PE. Patients were propensity-matched according to the probability of a patient receiving a reduced- dose of alteplase.

Outcome measurement

  • Primary outcome: all-cause and PE-related mortality or hemorrhage within 7 days of alteplase administration.
  • Secondary outcomes: shock index at 8 hours after alteplase administration, LOS.

Study Results:

  • A total of 284 patients were included in the retrospective analysis; 98 were treated with the full-dose and 186 with the reduced-dose alteplase regimen.
  • Primary outcome was similar in both groups:
    • 7-day all-cause (5.6% in full- dose vs. 8% in reduced-dose, p = 0.45) 
    • PE-related (4% in full-dose vs. 4.2% in reduced-dose, p = 0.93)
  • All other secondary outcomes were similar between both groups
  • overall rates of hemorrhagic complications were significantly lower in the reduced-dose group than in the full-dose group (13% vs. 24.5%, respectively, p = 0.014).
  • Major intracranial hemorrhage was higher, but not statistically significant, for full-dose group: 1.3% in reduced-dose vs. 7.1% in full-dose for major, (p = 0.067)

Discussion:

  • Overall, there was more risk for full-dose. However, this is a retrospective study so whether it will be factored into clinical practice remains to be seen.
  • The PERT team at UMMC still recommends full dose for hemodynamic unstable patients. Perhaps for those with somewhat instability, a half dose should be considered?
  • There is still not enough data regarding the newer ones, as UMMS hospitals are starting to use TNK more frequently nowadays.

Conclusion

In this retrospective, Propensity-score matching study, the full-dose regimen but is associated with a lower risk of bleeding.

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Category: Ultrasound

Title: POCUS for Pleural Effusion

Keywords: Pleural Effusion; POCUS (PubMed Search)

Posted: 4/22/2024 by Alexis Salerno, MD (Emailed: 4/29/2024) (Updated: 4/29/2024)
Click here to contact Alexis Salerno, MD

How do you look for signs of a pleural effusion with ultrasound?

Place your ultrasound probe in the mid axillary line with the probe marker placed towards the patient's head. 

Find the movement of the diaphragm and scan just above the diaphragm.

In normal lung, air scatters the ultrasound signal, and you are not able to see structures above the diaphragm.

With a pleural effusion, you can see:

  • anechoic fluid above the diaphragm
  • consolidated lung moving like a jelly fish
  • the spine above the diaphragm



In a cohort of  93,512 ED patients discharged with a diagnosis of hypertension there were 4400 who received a prescription for antihypertensives. The group receiving a prescription had fewer 30 day revisits and adverse events such as MI, CHF, etc. 

Previous study’s have found it is safe to prescribe antihypertensives from the ED. 

 This study is limited by the fact it is not a randomized control trial and there are many variables as to why the select patients received prescriptions  

The authors conclude: “Prescription antihypertensive therapy for discharged ED patients is associated with a 30-day decrease in severe adverse events and ED revisit rate.”

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New progress in head injury prevention in football

A Guardian Cap is a soft padded soft shell worn over football helmets.

Think of it like a shock absorber

It is intended to mitigate energy transfer to the head and neck during player impacts.

It retails for about $70 on amazon!

https://www.pinkvilla.com/pics/855x855/236466742_untitled-design-2024-04-27t133219-626_202404.jpg

Most NFL players have worn these caps during preseason practices for the past 2 years.

The NFL found a 52% reduction in preseason concussions (at the same position) between players who wore the cap versus those who did not.

In laboratory testing the Guardian cap reduced head impact forces by up to 1/3rd in certain impacts. 

Per NFL analytics, the Guardian cap absorbs 10% of the traumatic force. 

Additionally, if two players suffer a helmet to helmet hit in which each wears the cap, the impact force is reduced by 20%!

The NFL has allowed players to wear the caps this year 

They will have the team logos on them 

2024 season:  Players will wear the caps or one of 6 approved helmets (position specific) that provide equal or better protection.

If your child plays football, consider investing in this product as a potential means to reduce head impact forces and concussion.

More data is needed during regular season games with full speed collisions.



A small study retrospectively looking at recorded calls to a level 1 trauma center transfer line specifically looking at patients who died or were discharged to hospice without surgical intervention found only 10% had goals of care discussed prior to transfer. Most were brain hemorrhage patients. 
As a transferring facility, clearly outlining goals of care and addressing futility of care can have a major impact on trauma transfers and the cost and family burden associated with transfers.

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Background:

           -Muscle rigidity has been described as a side-effect of fentanyl, specifically activation of expiratory muscles 

           -Excessive expiratory muscle use acts as “anti-PEEP,” causing lung derecruitment and hypoxemia

           -End-expiratory lung volume (EELV) has been used as a surrogate for lung recruitment

Study:

          -Small, two center, observational study (46 patients with ARDS)

          -50% of  patients had a significant increase in EELV after administration of neuromuscular blockade (NMB)

          -Statistically significant correlation between a higher dosage of fentanyl and a greater increase in EELV after NMB

Takeaways:

          -NMB can improve lung recruitment for a subset of patients with ARDS, particularly in patients with significant expiratory muscle use (this can be seen on your physical exam of your intubated ED boarding patient)

          -Although this was not the main point of this study, consider fentanyl-associated “anti-PEEP,” particularly in patients receiving fentanyl whose hypoxemia and/or ventilator mechanics are disproportionate to their imaging

                    -This can be assessed with NMB (but ensure the patient will have adequate minute ventilation first)

                    -Naloxone has also been shown to reverse fentanyl-associated rigidity, but obviously would induce patient discomfort/withdrawal

*Of note, because this was an observational trial, it is possible that the patients with increased work of breathing were simply given more fentanyl. Regardless, these findings are consistent with previously documented physiologic side effects of fentanyl.

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PECARN  has a decision tool to identify blunt trauma patients under age 18 who are low probability for important intra-abdominal injuries. The questions to ask are:

  1.  Evidence of abdominal wall trauma/seatbelt sign
  2. GCS <14 with abdominal trauma
  3. Abdominal tenderness
  4. >1 of thoracic wall trauma, vomiting, complaint of abdominal pain, decreased breath sounds

Answering no to all yields  <0.1% chance of intra-abdominal trauma requiring intervention.  (See MedCalc link for other calculations)

A prospective validation study in the Lancet yielded 100% sensitivity and negative predictive value in 7542 patients under age 18  

This tool can likely be used to guide imaging choices in pediatric blunt abdominal trauma patients

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