UMEM Educational Pearls

Background:

There are also no clear guidelines regarding how fast fluid boluses should be administered, and there has been debate about whether different infusion rates could lead to different outcomes in patients receiving intravenous fluid (IVF) boluses (i.e. fast infusions may cause more third spacing due to the rapidity of the expansion of the intravascular space compared to fluid administered more slowly). A recent study compared IVF infusion rates in ICU patients.

-- Unblinded, randomized

-- 10,520 patients clinically requiring a fluid challenge, from 75 ICUs in Brazil

-- Infusion rate 333 mL/hr vs 999 mL/hr

   * (Trial also compared plasmalyte vs 0.9% saline, analyzed in separate study)

-- Some notable exclusion criteria: severe hypo/hypernatremia, AKI or expected to need RRT 6 hrs after admission

--Other caveats:

   * Faster infusion rates allowed at physician discretion in patients with active bleeding or severe      hypotension (SBP < 80 or MAP < 50 mmHg); patient was returned to assigned rate after condition resolved

   * Almost 1/2 the patients received at least 1L of IVF in 24 hours prior to enrollment

-- Results: No sig difference in 90-day survival, use of RRT, AKI, mechanical ventilator free days, ICU/hospital mortality/LOS 

Bottom Line: There is not yet compelling evidence that there are differences in patient outcomes in patients receiving fluid boluses given at 333 cc/hr vs. 999 cc/hr.

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Category: Orthopedics

Title: Chronic Exertional Compartment Syndrome (CECS)

Keywords: pressure, exercise, lower extremity (PubMed Search)

Posted: 8/14/2021 by Brian Corwell, MD (Updated: 2/23/2024)
Click here to contact Brian Corwell, MD

Chronic Exertional Compartment Syndrome (CECS)

 

Similar pathology to acute compartment syndrome except symptoms are related to activity (frequently running) and abate with rest.

95% involve lower extremity

Inappropriately elevated tissue pressure in one or more lower leg compartments associated with exercise

Anterior compartment most frequently involved

As tissue pressure increases, local perfusion is decreased. This leads to symptoms of pain, pressure, cramping and paresthesias.  

Also commonly associated with team sports such as soccer, lacrosse and field hockey.

More likely in competitive athletes than recreational.

Patient will be symptom free at time of ED evaluation

Make diagnosis of CECS with history

  1. Pain must be induced with exercise
  2. Usually limited to a single compartment, frequently the anterior
  3. Pain occurs at predictable time in exercise and forces athlete to stop running
  4. Pain resolves with rest
  5. If witnessed, tenderness is present only in the involved compartment and not elsewhere

Diagnosis with compartment pressure measurements done in office with treadmill exercise.

Non operatively, gait retraining programs have been shown to help symptoms. Appropriate if symptoms are mild.

Surgical treatment involves a minimally invasive fasciotomy

Post surgery success rates are between 63-100% with recurrence rates up to 20%

 

 



Approximately 15,000 children experience an in hospital cardiac arrest (IHCA) with little improvement in outcomes over the last two decades. During that time, epinephrine has been the constant basis for resuscitation of these patients. Current recommendations by the AHA recommend bolus dosing of epinephrine every 3-5 minutes in a pediatric cardiac arrest. Animal studies suggest that more frequent dosing of epinephrine may be beneficial. 

This was a retrospective study of 125 pediatric IHCAs with 33 receiving “frequent epinephrine” interval (≤2 minutes). Pediatric CPC score 1-2 or no change from baseline was used as primary outcome to reflect favorable neurologic outcome, with frequent dosing associated with better outcome (aOR 2.56, 95%CI 1.07 to 6.14). Change in diastolic blood pressure was greater after the second dose of epinephrine among patients who received frequent epinephrine (median [IQR] 6.3 [4.1, 16.9] vs. 0.13 [-2.3, 1.9] mmHg, p=0.034). 

This study is subject to all sorts of confounding and should be studied more rigorously, but suggests that more frequent dosing for pediatric IHCA may be of benefit.

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  • Generally a seasonal illness that circulates in fall/winter (Maryland’s season is October-April)
  • Following low incidence since April 2020, there is current ongoing circulation outside of the normal seasonal patterns
  • Updated regional trends are available via the National Respiratory and Enteric Virus Surveillance System (https://www.cdc.gov/surveillance/nrevss/rsv/index.html)
  • Causes upper respiratory illness characterized by copious nasal secretions which may cause increased work of breathing and necessitate hospitalization
  • Severity tends to peak at around day 5 of illness
  • In infants younger than 6 months, may also present with poor feeding, lethargy, or apnea
  • Risk of apnea is highest in premature infants (post conception age <48 weeks) and infants under 1 month of age
  • Routine administration of albuterol has not been shown to have benefit, the most recent AAP guidelines have a recommendation against trial of albuterol (common practices continue to be variable). It should be noted that children with severe disease were excluded from the studies used to make this recommendation.
  • Hypertonic saline administration has not shown to be helpful in the ED setting, but may decrease length of stay in patients being admitted
  • Consider admission for persistent tachypnea, hypoxia, inability to adequately feed, moderate to severe increased work of breathing at rest, or apnea

 

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Category: Critical Care

Title: Resuscitative Thoracotomy - 2 techniques

Keywords: Modified Clamshell thoracotomy, resuscitative thoracotomy, randomized control trial (PubMed Search)

Posted: 8/3/2021 by Kim Boswell, MD
Click here to contact Kim Boswell, MD

Resuscitative thoracotomy is a dramatic and heroic procedure used in the emergency department in an attempt to resuscitate a patient in arrest due to trauma. There are a few techniques commonly used, but due to the extreme nature of the procedure no prior randomized controlled trials (RCTs) have been done.

The modified clamshell thoracotomy (MCT) is a technique in which the standard left anterolateral thoracotomy (LAT) is extended across the sternum, but does not involve surgical opening of the right chest. The MCT allows for increased visualization of the mediastinum and thoracic cavity structures. 

Sixteen Emergency trained physicians (approximately half attending and half senior residents) from a level 1 trauma center underwent didactic and skill based training on both the MCT and LAT techniques using fresh, human cadavers. Following training they were randomized based on order of intervention, performing both techniques.

Their thoracotomies were assessed by a board certified surgeon and “success” was determined based on the complete delivery of the heart and cross clamping of the descending aorta. 

Primary outcome: time to successful completion of procedure

Secondary outcomes: successful delivery of the heart from the pericardial sac (as well as time to delivery),  cross clamping of the aorta (and time to clamping),  procedural completion and number of iatrogenic injuries. 

Overall, there was no statistical difference in primary outcome or successful completion between the MCT compared to the LAT (67% vs. 40%). However, 100% of the LAT resulted in some form of iatrogenic injury (rib fractures, lacerations of the diaphragm,/esophagus/heart/lung) compared to 67% of the MCT technique. There was no associated difference in success when previous experience (attending vs. senior resident) were compared. Lastly, MCT was the favored technique of the majority of the study subjects. 

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  • Testicular torsion is a straightforward diagnosis ultimately based on lack of blood flow to the affected painful, swollen testicle.
  • Testicular torsion is the most common cause of acute unilateral testicular pain in peripubertal boys due to rapid increase in testicle size during puberty.
  • Infarction begins as soon as after 2 hours of ischemia.
  • There is nearly a 100% salvage rate if blood flow is re-established within 6 hours.
  • Intermittent testicular torsion is challenging to diagnosis due to spontaneous resolution of symptoms and return of normal blood flow during ultrasound.
  • Beware complaints of repeated episodes of acute unilateral testicular pain and swelling.
  • Up to 50% of boys with testicular torsion reported at least one prior similar episode of acute pain and swelling. 
  • Ultrasound findings of a whirlpool sign (spiral-like pattern of spermatic cord), boggy spermatic cord, and a psuedomass of the distal spermatic cord are concerning even in the setting of normal blood flow.
  • Bottom Line: Peripubertal boys presenting with complaints of acute unilateral testicular pain and swelling should always be referred for urgent follow up even if their symptoms have resolved and when ultrasound may show normal blood flow as intermittent testicular torsion can not be ruled out.

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The much anticipated REMAP-CAP trial was epublished ahead of print July 12th in Intensive Care Medicine.  It was an RCT investigating four antiviral strategies in critically ill adults with COVID-19: lopinavir-ritonavir, hydroxychloroquine, a combination of the two, and no antiviral therapy (control group).  

Despite the hype around protease inhibitors, hydroxychloroquine, and other unproven therapies in COVID (lookin at you next, Ivermectin...), all three strategies had WORSE outcomes than placebo.  They all decreased organ-support-free days (all reaching statistical significance), which was the primary outcome.  They also all led to longer ICU time, longer time to hospital discharge, and reduced 90 day survival.  Not only does this study show no benefit, it shows fairly convincing signs of harm to these therapies.

 

Bottom Line: Protease inhibitors (e.g. lopinavir-ritonavir) and hydroxychloroquine are unproven therapies for critical COVID-19 infection, and are not recommended.  Providers should focus on interventions with demonstrated benefit, most notably steroids and good supportive/critical care.  

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Low dose ketamine was compared  to morphine for the treatment of patients with long bone fractures

 

 

126 patients with upper and lower extremity long bone fractures were divided into two treatment groups

  1. IV morphine at a dose of 0.1 mg/kg
  2. IV ketamine at a dose of 0.5mg/kg

 

Pain scores were compared pre and at 10 minutes post treatment

Pain severity significantly decreased in both groups to a similar degree

Increase adverse effects (emergence phenomenon) noted in ketamine group but all effects resolved spontaneously without intervention.

Conclusion:  Analgesic effect of ketamine is similar to morphine in patients with long bone fractures.

 

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Category: Critical Care

Title: HLH in the ED

Posted: 7/20/2021 by Mike Winters, MD (Updated: 2/23/2024)
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: 2/23/2024)
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: 2/23/2024)
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.

Methods

  • 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

 

Result

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) 

 

Pre-legalization

Peri-post legalization

P value

Monthly ED visit

2.1 (IRQ: 1.9-2.5)

1.7 (IQR: 1.0-3.0)

0.69

ICU admission

4.7%

13.6%

0.02

Respiratory symptoms

50.9%

65.9%

0.05

Altered mental status

14.2%

28.8%

<0.01

Age < 12 years

3.0%

12.1%

0.04

Unintentional exposure

2.8%

14.4%

0.02

Edible ingestion

7.8%

19.7%

0.02

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)

 

Conclusion

  • 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.
 
Background:
• 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

Infections

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]
 
Conclusion:
• 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: 2/23/2024)
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).

Conclusion:

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: 2/23/2024)
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: 2/23/2024)
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%

 

Safety:

  • 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.

 

https://www.youtube.com/watch?v=IO2qC5qHVFE

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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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