Keywords: dabigatran reversal, Idarucizumab (PubMed Search)
Full cohort analysis idarucizumab for dabigatran associated bleeding was recently published in NEJM.
This study evaluated the laboratory correction of elevated ecarin clotting time or diluted thrombin time induced by dabigatran and time to either cessation of bleeding (Group A: patients with GI bleeding, traumatic bleeding, or ICH) or time to surgery (Group B: patients requiring surgical intervention within 8 hours).
Group A (n=301): Median time to the cessation of bleeding was 2.5 hours in 134 patients.
Group B (n=202): Median time to intended surgery after infusion of idarucizumab was 1.6 hours.
100% reversal of abnormal ecarin clotting time or diluted thrombin time within 4 hours after the administration
Authors concluded thate idaurcizumab is an "effective" reversal agent for dabigatran.
Overall, the findings are more promising compared to the interim analysis that was published in 2015.
Infusion of idarucizumab decreased the dabigatran level from 110 ng/mL (Group A) and 73.6 ng/mL (Group B) to < 20 ng/mL.
Rebound levels of > 20 ng/mL were noted in 191 patients after 12 – 24 hours after idarucizumab adminiatration
Thrombotic events occured in 24 patients (14 in Group A and 10 in Group B) within 30 days after treatment
Serious adverse events occured in 23.3% of the patients within 5 days.
Most frequent events were:
Pollack CV et al. Idarucizumab for dabigatran reversal - full cohort analysis. N Eng J Med 2017;377:431-41.
Keywords: meningitis, CSF, glucose, glucometer (PubMed Search)
Category: Critical Care
Archinger SG, Ayus JC. Treatment of hyponatremic encephalopathy in the critically ill. Crit Care Med. 2017; epub ahead of print.
Keywords: Febrile seizure, meningitis (PubMed Search)
Febrile seizures occur in children 6 months through 5 year olds. A complex febrile seizure occurs when the seizure is focal, prolonged (> 15 min), or occurs more than once in 24 hours.
The prevalence of bacterial meningitis in children with fever and seizure after the H flu and Strep pneumomoniae vaccine was introduced is 0.6% to 0.8%. The prevalence of bacterial meningitis is 5x higher after a complex than simple seizure.
From the study referenced, those children with complex febrile seizures who had meningitis all had clinical exam findings suggestive of meningitis. More studies are needed to provide definitive guidelines about when lumbar punctures are needed in these patients.
This study was a retrospective review of children aged 6 months to 5 years who had complex febrile seizures in France between 2007-2011.
Children were excluded if they had a simple febrile seizure, history of non-febrile seizure, conditions associated with a higher risk of seizure (cerebral malformations, genetic syndrome, trauma in the previous 24 hours) or predisposing to bacterial meningitis (sickle cell, cancer, immunosuppressive treatments). Outcomes were the diagnosis of bacterial or HSV meningitis at 7 days
The rate of bacterial meningitis was 0.7% (CI 0.2-1.6). There were no cases of HSV meningitis.
69% of the study patients did not have a lumbar puncture, however, follow up was done by repeat exam, phone and review of the meningitis and also death registry if the patient was lost to follow up.
The clinical exam in the 5 children with bacterial meningitis was suggestive of meningitis (irritability, altered mental status, bulging fontanel). In a subgroup of patients without physical exam findings suggestive of meningitis, there were no cases of bacterial meningitis.
Guedji R et al. Do All Children Who Present With a Complex Febrile Seizure Need a Lumbar Puncture? Annals of Emergency Medicine. 2017; 70 (1):52-62.
Category: International EM
Keywords: suicide, clinical policies, risk-assessment tools (PubMed Search)
In patients presenting to the ED with suicidal ideation, physicians should not use currently available risk-assessment tools in isolation to identify low-risk patients who are safe for discharge. The best approach to determine risk is an appropriate psychiatric assessment and good clinical judgment, taking patient, family, and community factors into account. (Level C Recommendation, based upon the quality of the research.)
As noted in a previous Pearl (see August 2, 2017), the American College of Emergency Physicians recently published a methodological rigorous clinical policy entitled “Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department.”
Another question addressed within the document was the following: “In the adult patient presenting to the ED with suicidal ideation, can risk-assessment tools in the ED identify those who are safe for discharge?”
They determined that in patients presenting to the ED with suicidal ideation, physicians should not use currently available risk-assessment tools in isolation to identify low-risk patients who are safe for discharge. The best approach to determine risk is an appropriate psychiatric assessment and good clinical judgment, taking patient, family, and community factors into account. (Level C Recommendation, based upon the quality of the research.)
Category: Critical Care
Keywords: autoimmune, rheumatology, thrombosis, hematology (PubMed Search)
Catastrophic Antiphospholipid Syndrome (CAPS):
A life-threatening “thrombotic storm” of multi-organ micro & macro thrombosis in patients with antiphospholipid syndrome (known or unknown).
Triggered circulating antibodies (usually by infection, but can be prompted by malignancy, pregnancy, and lupus itself) cause endothelial disruption and inflammation leading to prothrombotic state, commonly with SIRS response.
Mortality is high at an estimated 40%.
Confirm diagnosis with antiphospholipid antibody titers.
Treat ASAP with unfractionated heparin, corticosteroids, and Hematology consultation for plasma exchange and/or IVIG.
Kazzaz NM, McCune WJ, Knight JS. Treatment of catastrophic antiphospholipid syndrome. Curr Opin Rheumatol. 2016;28(3):218-27.
Cervera R, Rodriguez-Pinto I, Colafrancesco S, et al. 14th International Congress on Antiphospholipid Antibodies Task Force. Report on catastrophic antiphospholipid syndrome. Autoimmun Rev 2014; 13:699–707.
Keywords: pituitary apoplexy, subarachnoid hemorrhage, meningitis, headache, CT, MRI (PubMed Search)
Bottomline: Keep pituitary apoplexy in your differential when considering SAH or meningitis, especially in the presence of risk factors, and have a low threshold to order an MRI.
Keywords: Gastroparesis, haloperidol (PubMed Search)
Take Home Point: In patients with diabetic gastroparesis, haloperidol may be an effective adjunctive treatment to prevent hospitalizations and reduce opioid requirements.
Study Design: single-center, retrospective review, case-matched to prior visit for gastroparesis
52 patients with previously diagnosed diabetic gastroparesis by gastric motility study who presented to the ED for gastroparesis treatment
Haloperidol administered visit
Haloperidol NOT administered visit (most recent visit, >7 days prior to haloperidol visit)
Baseline characteristics: median age 32 (21-57), 62% (32/52) female
Statistically significant reduction in hospital admissions for the haloperidol visit: (5/52 [10%] [CI 3-21%]) vs the non-haloperidol visit (14/52 [27%] [CI 16-41%]) p=0.02
Statistically significant reduction in opioid administration during the haloperidol visit: 6.75 ME (IQR 7.93) vs 10.75 ME (IQR 12) p=0.009
No difference in ED LOS, hospital LOS or need for additional antiemetics/prokinetics
No dystonic reactions, akathesia, excessive sedation, or cardiovascular complications in patients who received haloperidol
Small, single-center, retrospective study that only included patients with diabetic gastroparesis
Only intramuscular administration was studied
Baseline QT not reported
Young patient population, no description of comorbidities or home medications
Haloperidol may be considered as an adjunctive therapy in patients with diabetic gastroparesis for its antiemetic and analgesic properties. Prospective studies are necessary to confirm findings.
Ramirez R, Salcup P, Croft B, Darracq MA. Am J Emerg Med 2017;35:1118-1120.
Category: International EM
Keywords: Mental health, routine laboratory test, acute psychiatric patient (PubMed Search)
Patients with psychiatric disorders are found globally, with a recent global burden of disease estimate that mental illness accounted for 32.4% of years lived with disability and 13.0% of disability-adjusted life-years.
The American College of Emergency Physicians just published a methodological rigorous clinical policy entitled “Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department.”
One question they sought to answer was “In the alert adult patient presenting to the ED with acute psychiatric symptoms, should routine laboratory tests be used to identify contributory medical conditions (nonpsychiatric disorders)?”
Their assessment was: “Do not routinely order laboratory testing on patients with acute psychiatric symptoms. Use medical history, previous psychiatric diagnoses, and physician examination to guide testing.” This was a Level C recommendation, based upon the quality of the research.
Bottom Line: Current literature does not support routinely ordering laboratory testing on patients with acute psychiatric symptoms. However, the quality of the evidence was not strong and local clinical context should be considered.
Category: Critical Care
Keywords: RV dysfunction, APRV, echo, ultrasound (PubMed Search)
--RV systolic function is negatively affected by high RV afterload
--High mean airway pressures on the ventilator (particularly in modes such as APRV [airway pressure release ventilation]) can induce RV dysfunction
*****CLICK BELOW FOR A GREAT CASE!!!*****
A 25yoF with ARDS is on APRV (36/0 and 5/0.5). She is on norepi to maintain a MAP >65. A bedside echo reveals a dilated, dysfunctional RV.
--Open "A4C end diastole"
Measurement of TAPSE confirms the RV dysfunction, but also reveals the cause.
Every 5th beat, the TAPSE significantly improves to "normal" range. The four beats inbetween are abnormal. The 5th normal beat coincides with the APRV relase, when airway pressures are zero! Thus, this change in RV function is from the ventilator alone. The TAPSE decreases by almost 40%!
--Open "TAPSE measured"
Be careful with high mean airway pressures in patients with known or suspected RV dysfunction. This is why we try to avoid intubation in HD significant pulmonary embolism!
The answer appears to be ... it depends.
Early Oseltamivir Treatment in Influenza in Children1-3 Years of Age: A Randomized Controlled Trial
A study in 2010 out of Finland by Heinonen, et al showed that if given in the first 12 hours of symptom onset to otherwise healthy pediatric patients between the age of 1-3 years:
- decrease incidence of acute otitis media by 85%
- no difference if given within 24 hours
Among children with influenza A, oseltamivir started within 24 hours of symptom onset
- shortened medium time to resolution of illness by 3.5 days (3.0 versus 6.5) in all children
- shortened median time to resolution of illness by 4.0 days in UNvaccinated children
- Reduced parental work absenteeism by 3 days
* no differences were seen in children with influenza B *
- Single Center study in Finland
- The authors received support from the drug manufacturer
- The sample size of children with confirmed influenza cases with small (influenza A: 79, influenza B: 19)
If you have a patient between the age of 1-3 years with very early symptoms concerning for flu, a positive rapid influenza A test could allow you to cut her symptoms by 3 days, prevent complications, and allow parents to go back to work sooner.
Heinonen S, Silvennoinen H, Lehtinen et al. Early oseltamivir treatment of influenza in children 1-3 years of age: A randomized controlled trial. Clin Infect Dis. 2010;51(8):87-94.
Keywords: salicylate poisoning, endotracheal intubation, hemodialysis (PubMed Search)
Patients with severe salicylate poisoning may require endotracheal intubation due to fatigue from hyperventilation or mental status change.
A previously published study (Stolbach et al. 2008) showed that mechanical ventilation increases the risk of acidemia and clinical deterioration.
A small retrospective study investigated the impact of hemodialysis (HD) in intubated patients with salicylate poisoning.
53 cases with overall survival rate of 73.2%
In patients with salicylate level > 50 mg/dL
If salicylate level > 80 mg/dL
There is moratality benefit of HD in intubated salicylate-poisoned patient.
McCabe DJ, Lu JJ. The association of hemodialysis and survival in intuated salicylate-poisoned patients. Amer J Emerg Med 2017;35:899-903.
Stolbach QI, Hoffman RS, Nelson LS. Mechanical ventilation was associated with acidemia in a case series of salicylate-poisoned patients. Acad Emerge Med 2008;15;866-869.
Category: Critical Care
Improving Resuscitation Performance
Lauria M, et al. Psychological skills to improve emergency care providers' performance under stress. Ann Emerg Med. 2017; epub ahead of print.
Keywords: Knee instability (PubMed Search)
PCL injuries can sometimes have involvement of the posterolateral corner (PLC)
The dial test can be used to diagnose posterior lateral instability and help differentiate it from isolated PCL injuries
The dial test involves comparing the amount of external rotation of the lower leg at the knee while the knees are in 30° and in 90° of knee flexion.
An isolated injury to the posterolateral corner will result in more than 10° of external rotation in the injured knee that is present at 30° but not at 90° of knee flexion.
Keywords: CT scans, radiation exposure, pediatrics (PubMed Search)
Ventricular shunt (VP) malfunction can be severe and life-threatening and evaluation has typically included a dry CT brain and a shunt series which includes multiple x-rays of the skull, neck, chest and abdomen. The goal of this study was to decrease the amount of radiation used in the evaluation of these patients since these patients will likely present many times over their lifetime. Several institutions have more towards a rapid cranial MRI, however, this modality may not be readily available.
This multidisciplinary team decreased the CT scan radiation dose from 250mA (the reference mA in the pediatric protocol at this institution) to 150 mA which allows for a balance between reducing radiation exposure and adequate visualization of the ventricular system. They also added single view chest and abdominal x-rays.
The authors found that after implementing this new protocol, there was a reduction in CT radiation doses and number of x-rays ordered with no change in the return rate.
Marchese et al. Reduced Radiation in children presenting to the ED with Suspected Ventricular Shunt Complication. Pediatrics. 2017; 139 (5).
Keywords: Vaginal pearls, intravaginal foreign bodies (PubMed Search)
Vaginal douching is a common and potentially dangerous practice. Women engage in this practice predominately for personal hygiene reasons but also with the false belief it will prevent or treat infections and for contraception. Numerous public health agencies and medical societies discourage douching as it has been associated with many adverse outcomes including pelvic inflammatory disease, bacterial vaginosis, cervical cancer, low birth weight, preterm birth, human immunodeficiency virus transmission, sexually transmitted diseases, ectopic pregnancy, recurrent vulvovaginal candidiasis, and infertility.
An increasing fad is the use of intravaginal detox products. Claiming to enhance female health by removing toxins, these mesh cloth-covered balls containing herbs such as mothersworth, osthol, angelica, borneol, and rhizoma, not FDA-approved, are inserted into the vagina for 3 days. Clinical experience demonstrates these products decompose into numerous pieces which become scattered retained intravaginal foreign bodies, cause mucosal irritation, and thereotically could serve as a nidus for serious infections.
Category: Critical Care
Keywords: Resuscitation, CPR, family, policy (PubMed Search)
When surveyed, half of general medicine patients interviewed stated that they would prefer to have a loved one present if they were to develop cardiac arrest and require CPR. So far, studies have demonstrated that…
Allowing family presence during CPR is associated with the following benefits to family members:
And is NOT associated with a difference in:
Several studies have demonstrated benefits to patient family members who are offered the opportunity to witness ongoing CPR when their loved one develops cardiac arrest. These benefits--decreased rates of PTSD-related symptoms, anxiety, depression (including need for medication, professional treatment, and suicide attempts), and complicated grief--have been shown to persist at 1 year post-resuscitation event.
Themes that arise when discussing the resuscitations with family members afterward include:
1. The feeling of active involvement in the resuscitation process
2. Communication with the resuscitation team
3. Perception of the reality of death
4. Experience of and reaction to witnessing (or not witnessing) the resuscitation
Twelve percent of family members who chose to NOT be present during CPR expressed regret at their choice, versus three percent of relatives who chose to be present.
Negative outcomes cited by family members who witnessed CPR involved feeling like they were not being communicated with, or that their loved one was being over-zealously resuscitated.
Keywords: nursemaid, elbow (PubMed Search)
Take Home Points:
The Hyperpronation Method: This reduction technique for a nursemaid's elbow (radial head subluxation) has been found to have better first attempt success than classic supination/flexion technique and less painful. (Pediatrics July '98).
Click here to see a video of the technique https://youtu.be/-0ROu4hCXwQ?t=1m15s
Keywords: hydrogen peroxide (PubMed Search)
Hydrogen peroxide (H2O2) is a common household liquid that is used for wound irrigation/antiseptic and cosmetic purposes. The concentration of household product is 3% to 5% and is considered to be relatively safe except in large volume ingestion.
High-concentration H2O2 (>10%) is commercially available as “food grade” (35%) that is diluted for household use or for alternative medicine therapy (i.e. hyperoxygenation).
Ingestion of high-concentration of H2O2 can result in caustic injury as well as ischemic injury from gas embolism.
Ingestion of 1 mL of 3% H2O2 produces 10 mL of O2 gas while 1 mL of 35% H2O2 produces 115 mL of O2 gas.
Common symptoms/findings of H2O2 ingestions includes:
A retrospective review of >10% H2O2 ingestion from National Poison Data System showed:
Hatten BW et al. Outcomes after high-concentration peroxide ingestions. Ann Emerg Med. 2017;69:726-736.
Keywords: Terson syndrome, vitreous hemorrhage, intraocular hemorrhage, subarachnoid hemorrhage (PubMed Search)
50 YOF with acute onset of worst headache of life associated with nausea and vomiting. Patient is somnolent, will rouse to noxious stimuli and complains of a headache as well as decreased vision.
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