Category: Critical Care
Beesley S, et al. Septic cardiomyopathy. Crit Care Med 2018. [epub ahead of print]
Category: Pharmacology & Therapeutics
Keywords: Epinephrine, Asthma (PubMed Search)
Patients with severe asthma exacerbations that are unresponsive to inhaled beta-agonists may require the use of epinephrine to control their symptoms. When patients get to this point what route of administration should be used for the administration of epinephrine?
The most recent asthma guidelines (published in 2007) recommend the use of SubQ epinephrine 0.3-0.5 mg every 20 minutes for 3 doses. Drug references typically list SubQ or IM epinephrine 0.01 mg/kg (~0.3-0.5 mg) every 20 minutes as appropriate routes of administration. There is currently no data demonstrating that one route of administration is better than the other in patients with asthma; however, in other disease states, such as anaphylaxis, IM epinephrine is preferred due to the more rapid and reliable absorption over SubQ administration.
Auto-injectors that administer IM epinephrine 0.3 mg are available. These auto-injectors may decrease the risk of medications error; however, they can be expensive. SubQ administration requires the use of a syringe and a vial/ampule of 1 mg/mL epinephrine.
Bottom Line: Either SubQ or IM epinephrine administration is appropriate for patients with severe asthma exacerbations. The preferred method at a given institution will be dictated by historical practice, risk of medication dosing errors, and drug cost.
1. National Asthma Education and Prevention Program, Third Expert Panel on the Diagnosis and Management of Asthma. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma. Bethesda (MD): National Heart, Lung, and Blood Institute (US); 2007 Aug. Available from: https://www.ncbi.nlm.nih.gov/books/NBK7232/
2.Simons FER, Ardusso LRF, Bilo MB, El-Gamal YM, Ledford DK, Ring J, et al. World Allergy Organization Anaphylaxis Guidelines: Summary. J Allergy Clin Immunol. 2011;127(3):587–93. e1-e20.
Keywords: Delirium, dementia, screening, altered (PubMed Search)
A recent study was undertaken to validate the 4A's Test for the assessment of delirium in the elderly, with particular focus on inpatient geriatric patients; it revealed that the tool had high sensitivity in detecting delirium, particularly in those with dementia or language barriers, in whom this diagnosis can often be difficult to make. Further studies would be useful in a similar demographic of emergency department geriatric patients to confirm that this straightforward test is generalizable to the emergency department geriatric patient population.
The 4A’s Test used for this study was accessed from www.the4AT.com (Free Access).
The 4AT consists of four items with a maximum achievable score of 12.
Item 1 determines patient’s level of alertness by operator observation (maximum score 4).
Items 2 and 3 screen cognition and attention with the use of the Abbreviated Mental Test-4 (AMT-4) (maximum score 2) and Months Backwards (maximum score 2).
Item 4 assesses for ?uctuation and acute changes in mental state (score 0 or 4).
A score of 0 indicates delirium or cognitive impairment is unlikely.
A score between 1 and 3 indicates possible cognitive impairment (corresponding to stand alone dementia screening tools).
A score of 4 and above is suggestive of delirium.
Keywords: NAT, non-accidental trauma, abusive head trauma, intra-abdominal injury, burns (PubMed Search)
In addition to suspicion of NAT with traumatic brain injury and burns, remember these other high risk injuries and features:
- Duodenal injuries in children <4 y/o
- Frena injuries in non-ambulating children
- Proximal and midshaft humeral fractures > supracondylar fractures
- Any bruising on the trunk, ears, neck, or with larger size or pattern
- Delay in seeking care, inconsistent history, mechanism inconsistent with developmental age, and blame of a sibling or other child inflicting harm are all historical features also high risk.
Non-accidental trauma (NAT) continues to be a sad, but prevelant pathology in the United States. It is estimated that one million children in the US have been victims of maltreatment. As high as one third of children with NAT had the abuse missed on prior medical evaluation. There are several screening tools and clinical prediction rules that have been developed for clinical use, but none are to be used as substitutes for full skeletal survey and CT scan when indicated.
TEN-4 (clinical prediction rule): 97% sensitivity, 84% specificity with regards to NAT in the setting of bruising by age, location and characteristic.
PEDIBIRN (clinical prediction rule): 96% sensitive, 43% specificity with regards to abusive head trauma in children less than 3 years old.
PredAHT (clinical prediction rule): 72% sensitive, 86% specificity, also for abusive head trauma less than 3 years old.
PIBIS (screening tool): scoring system for well appearing infants presenting with brief resolved unexplained event (BRUE), previously called apparent life threatening event or ALTE.
Escobar, MA, et al. The association of nonaccidental trauma with historical factors, examination findings, and diagnostic testing during the initial trauma evaluation. Journal Trauma Acute Care Surgery. 2017; 82(6).
Category: Critical Care
Keywords: endotracheal intubation, cardiac arrest, airway, respiratory failure (PubMed Search)
Although the data is limited, current published rates of in-hospital, non-operating room peri-intubation cardiac arrest (PICA) range from 2 to 6%.1,2,3
Several risk factors associated with PICA have been identified and include:
Other common findings:
Bottom Line: Endotracheal intubation is one of the riskiest procedures we regularly perform as emergency physicians.
1. Heffner AC, Swords DS, Neale MN, Jones AE. Inicidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation. 2013; 84(11):1500-4.
2. Kim WY, Kwak MK, Ko BS, et al. Factors associated with the occurrence of cardiac arrest after emergency tracheal intubation in the emergency department. PLoS One. 2011; 9(11):e112779.
3. Wardi G, Villar J, Nguyen T, et al. Factors and outcomes associated with inpatient cardiac arrest following emergent endotracheal intubation. Resuscitation. 2017; 121:76-80.
Children less than 8 years, and especially infants, are more susceptible to upper cervical spine injury. Moreover, validated decision rules for suspected cervical spine injury imaging have not been proven to be as sensitive or specific for children less than 8 years of age.
The pediatric cervical spine has greater elasticity of the ligamentous structures, while the cartilaginous structures are less calcified. An infant's neck musculature is underdeveloped, with a disproportionally large head. These factors increase the risk of cervical spine injury, and can make it difficult to properly place protective cervical collars in infants while assessing them for injury.
In very young children, consider placing padding under the shoulders to prevent abnormal flexion that can occur with placement of a cervical collar, and consider having a lower threshold to image if mechanism history or exam is concerning.
Children are not little adults! Clinicians must acknowledge the anatomic differences, varying age-related ability to cooperate with examination, pediatric specific injury mechanisms, and decreased reliability of validated decision rules for imaging in children, especially when younger than 8 years old.
Murray BL, Cordle RJ: Pediatric Trauma, in Walls RM, Hockberger RS, Gausche-Hill M, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 9. Philadelphia, Elsevier 2018, (Ch) 165:p 2042-2057.
Leonard JR, Jaffe DM, Kuppermann N, et al. Cervical spine injury patterns in children. Pediatrics 2014; 133:e1179.
Keywords: headache, seizure, stroke, neurological deficit, thrombogenic (PubMed Search)
Long B, Koyfman A, Runyon MS. Cerebral Venous Thrombosis: A Challenging Neurologic Diagnosis. Emerg Med Clin N Am 35 (2017) 869–878
Keywords: Croup, epinephrine, discharge, observation (PubMed Search)
The peak age for croup is 6 months to 3 years. The cornerstone of treatment is corticosteroids, traditionally dexamethasone. With oral administration, the peak onset is 1-2 hours. Steroids shorten the duration of symptoms, reduce the need for nebulized epinephrine and decrease the need for intubation.
Racemic epinephrine has been used for moderate to severe croup and can show an improvement in patient symptoms for up to 120 minutes. There is little evidence to suggest how long to observe the patient for recurrence of symptoms after racemic epinephrine was given. Previous studies have suggested both 2 and 4 hour observation.
299 patients were included in this study. 136 patients were observed for 3.1 to 4 hours. In the 3.1 to 4 hour group, 21 (7%) failed treatment, 19 of those patients required admission and 2 returned within 24 hours. No patients who were discharged home after 4 hours returned to the emergency department within 24 hours.
Bottom Line: Consider a 4 hour period of observation after giving racemic epinephrine in order to decrease bounce backs.
Smith S, Giordano K, Thompson A and DePiero A. Failure of Outpatient Management With Different Observation Times After Racemic Epinephrine for Croup. Clinical Pediatrics. Epub ahead of print. Accessed October 2017.
Keywords: DAWN, thrombectomy, mismatch, wake-up, stroke, penumbra (PubMed Search)
Bottom Line: The use of neuroimaging to identify an ischemic penumbra that may benefit from thrombectomy may be considered even for patients with time of last known well beyond 6 hours.
Nogueira RG, Jadhav AP, Haussen DC, et al. Thrombectomy 6 to 24 hours after stroke with a mismatch between deficit and infarct. N Engl J Med. 2017 Nov 11. [Epub ahead of print]
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Category: Critical Care
Sedating The Critically Ill Patient
Metha S, et al. What's New in Intensive Care: Ten Tips for ICU Sedation. Intensive Care Med 2017. [epub ahead of print].
Keywords: 5th metatarsal, fracture, overuse (PubMed Search)
CC: 12yo boy presents with pain to base of 5th metatarsal
Osteochondrosis overuse syndromes associated with development of secondary ossification or apophyseal centers
Iselin disease – Osteochondrosis of 5th MT base
Lateral 5th foot pain with weight bearing and activity in early adolescence
Child may limp or walk on inner part of foot
Adolescents: Girls >10, Boys >12
Commonly seen in soccer, basketball, gymnastics and dance
Exam: Tenderness to palpation at proximal 5th MT at peroneal brevis insertion
Area may show edema and redness
Pain with foot inversion and resisted eversion and dorsiflexion
XR: May be normal or show enlargement or fragmentation of epiphysis
Obliquely oriented small bony fleck at 5th MT base. Parallel to long axis of 5th MT. Best seen on oblique view. Unlike fractures which tend to be horizontally oriented.
Treatment: Immobilize for comfort if severe (walking boot) or simple activity modification if mild. Ice and calf muscle stretching.
Keywords: Loperamide, cardiotoxicity, QT prolongation (PubMed Search)
Loperamide (Imodium) is a common inexpensive over-the counter antidiarrheal agent. It acts peripherally at the mu opioid receptor to slow gastrointestinal motility and has no CNS effects at therapeutic doses due to it's low bioavailability and limited abillity to cross the blood brain barrier dependent on glycoprotein transport. In the past few years, reports of loperamide abuse causing serious cardio toxicity began to appear in the literature. Abused at daily doses of 25-200 mg to get high or and to treat symptoms of withdrawal. (therapeutic dose: 2-4 mg with a maximun of 8mg for OTC and 16mg for prescription). Loperamide has been called the "poor man's methadone".
At large doses, loperamide effects the cardiac sodium, potassium and calcium channels which prolongs the QRS complex and can lead to ventricular arrhythmias, hypotension, and death. Clinical features includes:
Take Home Point:
Consider loperamide as a possible cause of unexplained cardiac events including QT interval prolongation, QRS widening, Torsades de Pointes, ventricular arrhythmias, syncope, and cardiac arrest. Intravenouse sodium bicarbonate should be utilized to overcome blockade and may temporize cardiotoxic events. Supportive measures necessary may include defibrillation, magnesium, lidocaine, isoproternol, pacing, and extracorporeal life support.
Cardiac Conduction disturbance after loperamide abuse. Marraffa JN, Holland MG, Clin Toxicol. 2014;52(9):952-957.
Poor man's Methadone: A case report of Loperamide toxicity.Dierksen J, Gonsoulin M, et al. Am J Forensic Med Pathol. 2015 Dec:36(4): 268-70.
FDA Drug Safety Communication: FDA warns about serious heart problems with high doses of the antidiarrheal medicine loperamide (Imodium), including from abuse and misuse [06-07-2016]. Available from: http://www.fda.gov/Drugs/DrugSafety/ucm504617.htm
Category: Infectious Disease
Keywords: c. difficile, antibiotic (PubMed Search)
Community-associated Clostridium difficile infection (CA-CDI) represents 41% of all CDI cases annually. The association of specific outpatient exposures was assessed in a case control study by Guh, et al. They reviewed the CDC’s active surveillance reporting from 10 states through the Emerging Infections Program (Maryland participates).
Cases: ≥18, + C. difficile stool specimen collected as an outpatient or within 3 days of hospitalization, with no overnight stay in a health care facility in the prior 12 weeks, and no prior CDI diagnosis
Controls: matched 1:1 for age and sex within the same surveillance catchment area as the case patient on the date of the collection specimen. Exclusion criteria: prior diagnosis of CDI, diarrheal illness, overnight stay in health care facility in the prior 12 weeks
Data Collection: telephone interview, standardized questionnaire or comorbidities, medication use, outpatient health care visits, household and dietary exposures in the prior 12 weeks
Results: 452 participants (226 pairs), over 50% were ≥ 60 years of age, 70.4% female, and 29% were hospitalized within 7 days of diagnosis, no patients developed toxic megacolon or required colectomy.
Cases had more health care exposures, including the emergency department (11.2% vs 1.4% p <0.0001), urgent care (9.9% vs 1.8%, p=0.0003). In addition, cases also reported higher antibiotic exposures (62.2% vs 10.3%, p<0.0001) with statistically significant higher exposure to cephalosporins, clindamycin, fluoroquinolones, metronidazole, and beta-lactam and/or beta-lactamase inhibitor combination. The most common antibiotic indications were ear or sinus infections, URI, SSTI, dental procedure, and UTI. No differences were found in household or dietary exposures.
Take-home point: This study highlighted the risk for CA-CDI infection for patients presenting to an ED and reiterates that exposures to fluoroquinolones, cephalosporins, beta-lactam and/or beta-lactamase inhibitor combinations, and clindamycin significantly increases the risk of CA-CDI infection. Reducing unnecessary outpatient antibiotic prescribing may prevent further CA-CDI. 36% of case patients did not have any antibiotic or outpatient health care exposure; therefore, additional risk factors may exist.
Alice Y Guh, Susan Hocevar Adkins, Qunna Li, Sandra N Bulens, Monica M Farley, Zirka Smith, Stacy M Holzbauer, Tory Whitten, Erin C Phipps, Emily B Hancock, Ghinwa Dumyati, Cathleen Concannon, Marion A Kainer, Brenda Rue, Carol Lyons, Danyel M Olson, Lucy Wilson, Rebecca Perlmutter, Lisa G Winston, Erin Parker, Wendy Bamberg, Zintars G Beldavs, Valerie Ocampo, Maria Karlsson, Dale N Gerding, L Clifford McDonald; Risk Factors for Community-Associated Clostridium difficile Infection in Adults: A Case-Control Study, Open Forum Infectious Diseases, Volume 4, Issue 4, 1 October 2017, ofx171, https://doi.org/10.1093/ofid/ofx171
Category: Critical Care
Severe acute respiratory failure among patients with PCP pneumonia, especially among those newly diagnosed with AIDS, remains a disease of high morbidity and mortality. Among those requiring mechanical ventilator support, the mortality rate has been reported between 50-70%.
According to ELSO guidelines, pharmacologic immunosuppression (specifically neurtrophil <400/mL) is a relative contraindication. Furthermore, a status predicting poor outcome despite ECMO should also be considered a relative contraindication.
That said, there are several case reports now of successful use of ECMO in AIDS patients, particularly those suffering with PCP pneumonia.
In a case report and literature review published in BMJ in Aug 2017, 11 cases of ECMO (including 1 VA) in AIDS patients were described.
Bottom Line: HIV/AIDS is not an absolute contraindication to VV ECMO therapy in ARDS and may be particularly useful in the treatment of severe PCP pneumonia. Initiation of ECMO in this patient population should be considered on an individual case by case basis.
Lee N, Lawrence D, Patel B, Ledot S. HIV-related Pneumocystis jirovecii pneumonia managed with caspofungin and veno-venous extracorporeal membrane oxygenation rescue therapy. 2017. doi:10.1136/bcr-2017-221214.
Category: Critical Care
Keywords: sepsis, resuscitation, obesity, IV fluids, bolus (PubMed Search)
We are all familiar with the Surviving Sepsis Campaign recommendation (& CMS core measure) for an initial 30ml/kg bolus of IV crystalloid within the first 3 hours for our patients with septic shock. There is minimal data, however, on how much IVF we should be giving our patients with BMIs ≥30.
A recent study in obese patients with septic shock retrospectively stratified the total fluids administered at 3 hours into 3 different weight categories, to categorize patients as having received 30mL per kg of ___ body weight, whether actual (ABW), adjusted (AjdBW), or ideal (IBW**).
AdjBW = (ABW – IBW) *40% + IBW
**IBW calculated using Devine’s formula for men and women:
Keywords: UTI, infection, elderly, symptoms, antibiotics (PubMed Search)
Asymptomatic bacteriuria is common and increases with age, with an incidence of up to 50% in women over the age of 70. Asymptomatic bacteriuria does not carry an associated high morbidity or mortality if left untreated; it is usually transient and resolves spontaneously. In order to decrease polypharmacy and possible drug interactions in our elderly patients, they should only be diagnosed with and treated for a UTI if they have laboratory evidence of a UTI (bacteriuria and pyuria) and have two of the following:
· Worsened urinary urgency or frequency
· Acute dysuria
· Suprapubic tenderness
· Costovertebral angle tenderness
Mody L, Juthani-Mehta M. Urinary Tract Infections in Older Women: A Clinical Review. JAMA. 2014;311(8):844-854. doi:10.1001/jama.2014.303.
Keywords: green urine (PubMed Search)
Different chemical, food or pharmaceutical agent exposure can change the color of the urine.
What could cause this patient's urine to turn green?
Green or greenish-blue color urine can result from exposure to follow substances:
The picture came from a patient who received methylene blue after being diagnosed with methemoglobinemia (65%).
Keywords: Stress fracture, runner, non union (PubMed Search)
Tibial shaft stress fractures
An overuse injury where the tibia is subjected to repetitive stress resulting in progressive microfractures
Commonly seen in runners and military recruits
Location of injury is very important for prognosis and treatment
1) Medial tibia (compression side) – Most common stress fracture site in athletes (runners)
2) Anterior tibia (tension side) – Seen in repetitive jumping athletes
History: Change in routine (volume or surface), Insidious onset of pain, worse with activity better with rest
Exam: Focal tenderness to palpation (versus larger diffuse area with shin splints)
Radiology: Plain film often normal in first 2 to 3 weeks
Lateral X-ray may show the “dreaded black line” on the anterior tibia
MRI has replaced bone scan as most sensitive for early diagnosis. Fracture line surrounded by edema.
Medial fractures: relative rest (avoid painful activities), avoid NSAIDs, PT, gradual return to activity as dictated by symptoms
Anterior stress fractures: Very high risk injury pattern (delayed union and non union). Non weight bearing splint/cast. Intramedullary nail often used for failure of conservative treatment or earlier return to sport in competitive athletes.
Dreaded black line picture:
Keywords: URI, AOM, wait-and-see, antibiotic stewardship (PubMed Search)
As we are approaching the winter in the northern hemisphere, the number of visits for ear pain or respiratory symptoms are expected to increase. The occurrence of acute otitis media (AOM) will also increase, but are these two disease processes related?
Drs. Heikkinen and Chonmaitree published a systematic review of previously reported studies regarding the correlation of these two disease processes (1). As far back as 1990, studies have shown that up to 94% of pediatric patients diagnosed with AOM have concomitant upper respiratory infection (URI) type symptoms at time of diagnosis (2). The viral infections most commonly associated with AOM are respiratory syncytial virus, influenza virus, and adenovirus (3).
The most commonly taught risk factors for developing AOM include young age, male gender, multiple siblings, day care attendance, and passive smoking. These factors are also related to the development of upper respiratory symptoms, and the development of AOM should be thought of as a complication of the upper respiratory infection (4).
Koivunen et al noted the highest incidence of AOM at day 3 after the onset of an URI, and the median time to diagnosis was day 4 (5). If you see a patient in day 2-4 of an URI, who has started to develop an ear effusion, but not clinical AOM, you may want to consider a “Wait-to-see” treatment option if the patient meets treatment criteria (https://em.umaryland.edu/
(1) Heikkinen T, Chonmaitree T. Importance of Respiratory Viruses in Acute Otitis Media. Clinical Microbiology Reviews. 2003;16(2):230-241.
Keywords: GBS, weakness, intubation, CSF, LP (PubMed Search)
Allen JA. Chronic Demyelinating Polyneuropathies. Continuum 2017;23(5):1310–1331