UMEM Educational Pearls

Category: Critical Care

Title: INSPIRATION Trial - AC prophylaxis in COVID patients

Keywords: COVID-19, Anticoagulation, Thromboembolism (PubMed Search)

Posted: 4/7/2021 by Mark Sutherland, MD
Click here to contact Mark Sutherland, MD

COVID-19 is generally regarded as a hypercoagulable state, and the role of pulmonary emboli and other VTE in COVID remains unclear.  As a result, how to optimally provide prophylactic anticoagulation in COVID-19 patients who are not known to have VTE has been a point of debate.  

The INSPIRATION trial looked at 600 patients admitted to academic ICUs in Iran, and compared what is often-referred to as "intermediate-dose" prophylaxis (in this case 1 mg/kg daily of enoxaparin) to standard dose prophylaxis (40 mg/day of enoxaparin).  The study utilized a combined endpoint of venous thromboembolism, arterial thromboembolism, need for ECMO, or mortality.  As a reminder, composite endpoints can skew results.  However, the dose and type of anticoagulant chosen is similar to many academic centers around the world, and pharmacy guidelines often recommend providing this type of "intermediate-dose" prophylaxis in COVID-19 patients, sometimes based on clinical status, d-dimer or other coagulation-related patient-data.  As with many things with COVID-19, this practice is based on limited data.

There was no significant difference between groups in the primary outcome (45.7% in intermediate ppx group vs 44.1% in standard group), and while safety outcomes were similar (major bleeding in 2.5% in the intermediate ppx group vs 1.4% in standard group), the intermediate regimen failed to demonstrate non-inferiority to the standard regimen for major bleeding.

Intermediate vs standard-dose ppx was similar in this study with a small, but statistically significant increase in major bleeding in the intermediate-dose group.

 

 

Bottom Line: Although this study had methodologic flaws and there are external validity concerns, the INSPIRATION trial supports the notion that standard dose (e.g. 40 mg/g/kg/day enoxaparin) and intermediate-dose (e.g. 1 mg/kg/day enoxaparin) VTE prophylaxis are equivalent in critically ill COVID-19 patients who do not already have a known VTE in terms of preventing negative VTE outcomes.  Intermediate-dose may be associated with increased bleeding.  As more critically ill patients require ED boarding, the dose of VTE prophylaxis may remain controversial, but the need to start it remains an important consideration.

 

 

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Category: Pharmacology & Therapeutics

Title: Outpatient Treatment of Pyelonephritis

Keywords: Pyelonephritis, Outpatient, Fluoroquinolones, TMP-SMX, Beta-lactams (PubMed Search)

Posted: 4/3/2021 by Wesley Oliver
Click here to contact Wesley Oliver

While fluoroquinolones have fallen out of favor for many indications due to the ever growing list of adverse effects, they still play an important role in the outpatient treatment of pyelonephritis. Fluoroquinolones and TMP-SMX are the preferred agents due to higher failure rates with beta-lactams.

 

Preferred Therapies:
Ciprofloxacin 500 mg PO BID*
Levofloxacin 750 mg PO daily*
TMP-SMX 1 DS tab PO BID**

 

*Consider a single dose of long-acting parenteral agent, such as ceftriaxone, if community prevalence of fluoroquinolone resistance >10%.
**Consider a single dose of long-acting parenteral agent, such as ceftriaxone, if using TMP-SMX.

 

Alternative Therapies#:
Cefpodoxime 200 mg PO BID
Cefdinir 300 mg PO BID

 

#Beta-lactams are not preferred agents due to higher failure rates when compared to fluoroquinolones. Consider a single dose of long-acting parenteral agent, such as ceftriaxone, if using beta-lactams.

 

Duration of Therapy: 10-14 days

 

Take Home Point:
Utilize ciprofloxacin, levofloxacin, or TMP-SMX over beta-lactams when discharging patients with oral antibiotics for pyelonephritis.

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Improving Compliance with Lung-Protective Ventilation

  • Approximately 250,000 ED patients are intubated and receive mechanical ventilation each year in the United States.
  • While emergency physicians understand the importance of providing lung-protective ventilation, current studies demonstrate that more than 40% of ED patients are placed on initial tidal volumes > 8 ml/kg of predicted body weight (PBW).
  • In many cases, this may be due to the inaccurate estimation of patient height when determining PBW.
  • In a recent single-center study, Tallman and colleagues evaluated a quality improvement intiative, whereby respiratory therapists were provided with a tape measure and an EHR BPA that reminded them to measure the patient's height for PBW.
  • In this study, these simple, low-cost interventions significantly increased compliance with lung-protective ventilation.
  • Take Home Pearl: Be sure to measure your intubated patient to accurately determine PBW and set the correct tidal volume.

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Diphenhydramine is commonly involved in overdose or misused. Although it is primarily used for its anti-histamine property, it also has significant antimuscarinic effect.

A recent retrospective study investigated the clinical characteristics associated with severe outcomes in diphenhydramine overdose using the multi-center Toxicology Investigators Consortium (ToxIC) Registry. 

Severe outcomes were defined as any of the following:

  • Seizure
  • Ventricular dysrhythmia
  • Intubation

 

Results

863 cases of isolated diphenhydramine ingestion were identified between Jan 1, 2010 to Dec 31, 2016

  • Females: 59.1% 
  • Age < 18 years: 51.3%
  • Intentional ingestion: 86.0%
    • Self-harm: 37.5%
    • Abuse/misuse: 11.5%

Most common symptoms:

  • Delirium/toxic psychosis: 40.1% (n=346)
  • Agitation: 33.1% (n=286)
  • Severe outcome: 15.6% (n=135)

Factors associated with severe outcome

  • Intubation: self-harm ingestion and male
  • Acidemia: pH <7.2
  • QRS prolongation: QRS > 120 msec
  • Elevated anion gap: AG >20

Conclusion

  • Acidemia, QRS prolongation and elevated anion gap was associated with severe outcome in diphenhydramine toxicity

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Category: Pediatrics

Title: When should troponin be ordered in a pediatric patient?

Keywords: Chest pain, ischemia, pediatrics, myocarditis (PubMed Search)

Posted: 3/19/2021 by Jenny Guyther, MD (Updated: 2/23/2024)
Click here to contact Jenny Guyther, MD

Even though acute myocardial ischemia (AMI) does not present as commonly in the pediatric patient as in the adult and the literature is limited, it is reasonable to obtain a troponin when acute cardiac ischemia is suspected based on the history and physical exam. 

Recreational drugs including cocaine, amphetamine, cannabis, Spice, and K2 (cannabis derivatives) have been shown to result in myocardial injury including AMI. Coronary vasospasm secondary to drug use is well documented in the pediatric population. While cocaine use is a known risk factor for coronary vasospasm, the same condition has been reported in pediatric patients after marijuana use.

In a study of pediatric patients with blunt chest trauma, 3 of 4 patients with electrocardiographic or echocardiographic evidence of cardiac injury had elevations in troponin I above 2.0 ng/mL. Cardiac troponins are an accurate tool for screening for cardiac contusion after blunt chest trauma in pediatric patients even with limited data.

Cardiac troponins are also useful in the evaluation for myocarditis. In one study, myocarditis was the most common diagnosis (27%) in pediatric ED patients presenting with chest pain and an increased troponin. Eisenberg et al showed a 100% sensitivity and an 85% specificity for myocarditis using a troponin of 0.01 ng/mL or greater as a cut off.  A normal troponin using this cutoff can be used to exclude myocarditis. Abnormal troponin in the first 72 hours of hospitalization in pediatric patients with viral myocarditis is associated with subsequent need for extracorporeal membrane oxygenation and IVIg.

Bottom line: Troponin can be used in pediatric patients with clinical concern for cardiac ischemia, cardiac contusion and myocarditis

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Category: Toxicology

Title: Occupational poisoning in the US

Keywords: occupational poisoning (PubMed Search)

Posted: 3/18/2021 by Hong Kim, MD, MPH (Updated: 2/23/2024)
Click here to contact Hong Kim, MD, MPH

 

There are different occupational hazards depending on the nature of one’s trade/skill/employment. Although healthcare providers may not always inquire about patient’s occupation, knowledge of a patient’s occupation may provide insightful information when caring for patients with acute poisoning.

From a recent retrospective study of National Poison Data System, the top 10 occupational toxicants were:

  1. Caustics (acids & alkalis)
  2. Chlorines/hypochlorites
  3. Carbon monoxide
  4. Hydrocarbons
  5. Cleansers/detergents
  6. Ammonia
  7. Cement
  8. Hydrofluoric acid
  9. Disinfectants
  10. Hydrogen sulfide

 

Top 10 occupational toxicants associated with fatalities were:

  1. Hydrogen sulfide
  2. Ammonia
  3. Carbon Monoxide
  4. Simple asphyxiants
  5. Chlorine/hypochlorites
  6. Alkalis
  7. Pyrethrins/pyrethroids
  8. Toluene/xylene
  9. Methane
  10. Methylene chloride 

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Question

The PARAMEDIC2 trial in NEJM 2018 studied the outcomes of the use of epinephrine in outside hospital cardiac arrest (OHCA) on survival and neurological outcome. 

Methods: Conducted in Britain, randomized 8007 patients to receive either epinepherine 1mg (n=4012) or placebo (n=3995) as part of standard CPR for out-of-hosptial arrest. Their primary outcome was survival at 30 days and their secondary outcomes included length of stay as well as neurological outcomes at 30 days and 3 months.

Results: The epinepherine group had improved survival to hospital admission (23% vs. 8%), at 30 days (3.2% vs. 2.4%) or at 3 months (3% vs. 2.2%). Favourable neurological outcomes, however, had no statistical difference at both hospital discharge and at 3 months.

Bottom line: Epinephrine improves ROSC, though with poor neurological outcomes. 

Important facts: 

  • Demographics: Mean age 69 years, 35% female
  • Initial cardiac rhythm: shockable 19%, Non-shockable 78%, Undetermined 2%
  • Cause of Cardiac Arrest: Medical 91% Traumatic 2%, Drowning 0.2%, substance overdose 2%, Asphyxia 3%, missing data 2%
  • Witness of cardiac arrest: none 37%, Paramedic 11%, Bystander 50%, missing data 1%
  • CPR Performed by: Paramedic 11%, bystander 59%, missing data 2%
  • Time from: emergency call to ambulance arrival 6min, emergency call to administration of drug 22 min, arrival to ambulance departure 50 min

 

Recently, a follow up of the PARAMEDIC2 trial was completed in Resuscitation. 

They reported long-term survival, quality of life, functional and cognitive outcomes at 3, 6 and 12-months.

Results:  At 6 months, 78 (2.0%) of the patients in the adrenaline group and 58 (1.5%) of patients in the placebo group had a favourable neurological outcome (adjusted odds ratio 1.35 [95% confidence interval: 0.93, 1.97]). 117 (2.9%) patients were alive at 6-months in the adrenaline group compared with 86 (2.2%) in the placebo group (1.43 [1.05, 1.96], reducing to 107 (2.7%) and 80 (2.0%) respectively at 12-months (1.38 [1.00, 1.92]). Measures of 3 and 6-month cognitive, functional and quality of life outcomes were reduced, but there was no strong evidence of differences between groups.

Bottom line: Epinephrine improves survival at 12 months, but poor neurological outcomes remain. 

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Category: Orthopedics

Title: Patellofemoral Syndrome

Keywords: patellofemoral, knee, pain (PubMed Search)

Posted: 3/13/2021 by Michael Bond, MD (Updated: 2/23/2024)
Click here to contact Michael Bond, MD

Bottom Line: In a recent meta-analysis the risk factors for patellofemoral syndrome are weak hip abduction strength, quadricep weakness in military recruits, and increased hip strength in adolescence.

PatelloFemoral Syndrome: Patellofemoral pain is not clearly understood and is believed to be multi-factorial.  Numerous factors have been proposed including muscle weakness, damage to cartilage, patella maltracking, as well as others.  Patient often complain of anterior knee that is aggravated by walking up and down stairs or squatting. Patellofemoral pain is extremely common. In the general population the annual prevalence for patellofemoral pain is approximately 22.7%, and in adolescents it is 28.9%.

Though commonly taught, the following have no evidence to support that they are a risk factor for patellofemoral syndrome: Age, Height, Weight, BMI, Body Fat or Q Angle of patella

 
 

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Category: Neurology

Title: The Rising Incidence of Idiopathic Intracranial Hypertension

Keywords: Idiopathic intracranial hypertension, IIH, pseudotumor cerebri, obesity, healthcare utilization (PubMed Search)

Posted: 3/10/2021 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

  • Idiopathic intracranial hypertension (IIH) predominantly affects women of childbearing age and is strongly associated with obesity.
  • Patients can have high rates of healthcare utilization due to their chronic disabling headaches, multiple diagnostic tests and specialist consultations, and potential complications related to treatments.
  • A recent study looked at trends in the incidence, prevalence, and healthcare outcomes of IIH in the 3.1 million Welsh population over a 14-year period.
    • Incidence of IIH increased from 2.3/100,000 to 7.8/100,000 (p<0.001).
    • Prevalence of IIH increased from 12/100,000 to 76/100,000 (p<0.001).
    • Obesity (BMI >30 kg/m2) also increased from 29% to 40% of the population (p<0.001), with IIH incidence and prevalence strongly associated with BMI.
    • Outcomes included blindness (0.78%), moderate visual impairment (1.9%), CSF diversion (9%) with 44% of these patients requiring at least 1 revision surgery.
    • IIH patients also had 5.28 times higher rate of unscheduled hospital visits during this time period.

Bottom Line: The incidence and prevalence of IIH is increasing, likely related to rising rate of obesity. This has also been associated with more healthcare utilization compared to the general population.

 

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Background:

The association between time intervals of ED antibiotic administration and outcome has been controversial.  While single studies showed there was increased mortality associated with delayed antibiotic administration (1-3). A meta-analysis of 13 studies and 33000 patients showed that there was no mortality difference between septic patients receiving immediate Abx (< 1 hour) vs. those receiving early abx (1-3 hours) (4).

Since delay in recognition of sepsis (defined as ED triage to Abx order) and delay in antibiotics delivery (Abx order to administration) contribute to total delay of Abx administration, a new retrospective study (3) attempted to investigate the contributions of either factor to hospital mortality.

Results:

The study used generalized linear mixed models and involved 24000 patients.

For All patients and outcome of hospital mortality:

Recognition delay (ED triage to Abx order): OR 2.7 (95% CI 1.5-4.7)*

Administration delay at 2-2.5 hours (Abx order to administration): OR 1.5 (1.1-2.0)

These results was associated with non-statistical significance in patients with septic shocks.

Conclusion:

Delayed recognition of sepsis was associated with higher hospital mortality.  Longer delay of abx administration was also associated with increased risk of hospital mortality.

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Tranexamic acid (TXA) is an antifibrinolytic medication that has been trialed in previous small studies to treat epistaxis. The data to this point has not reliably shown a reduction in bleeding at 30 minutes, but has demonstrated an increased rate of discharge at 2 hours and a reduction in re-bleeding events.

The NoPAC study was the largest study to date on TXA for epistaxis. It was a double-blind, placebo-controlled, randomized study of TXA in adult patients with persistent atraumatic epistaxis to determine if TXA use decreased the rate of anterior nasal packing. Patients were excluded if they had trauma, out of hospital nasal packing, allergy to TXA, nasopharyngeal malignancy, hemophilia, pregnancy, or if they were referred to ENT.

Eligible patients completed 10 minutes of first aid measures followed by 10 minutes of topical vasoconstrictor application prior to randomization to either placebo of 200mg TXA soaked dental rolls inserted in the nare.

496 patients were enrolled. The average patient was 70 years old with stable vitals 150/80mmHg, HR 80 bpm with >60% on oral anticoagulants.

TXA did not reduce the need for anterior nasal packing: 100 (41.3% placebo) vs 111 (43.7% TXA) OR 1.11 (0.77-1.59). There were no differences in the rates of adverse events.

Bottom Line: TXA does not improve rates of anterior nasal packing for patients with persistent epistaxis.

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Category: Toxicology

Title: Is standard NAC dosing adequate for "massive" acetaminophen overdose.

Keywords: massive acetaminophen overdose, standard NAC, hepatotoxicity (PubMed Search)

Posted: 3/4/2021 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

 

Recently, there has been questions if standard n-acetylcysteine (NAC) dose is adequate for massive acetaminophen (APAP) overdose (ingestion of > 32 gm or APAP >300 mcg/mL).

A retrospective study from a single poison center (1/1/2010 to 12/31/2019) investigated the clinical outcome of massive APAP overdose (APAP > 300 mcg/mL at 4 hour post ingestion) treated with standard dosing of NAC.

Results

1425 cases of APAP overdose identified; 104 met the criteria of massive APAP overdose. 

  • 300-449 mcg/mL: 59.6% (n=62)
  • 450-599 mcg/mL: 14.4% (n=15)
  • >600 mcg/mL: 25.9% (n=27)

 

  • No acute liver injury/hepatotoxicity: 76% (n=79)
  • Hepatotoxicity: 24% (n=25)

Among cases that received NAC within 8 hours post ingestion (n=44)

  • Only 9% (n=4) cases developed hepatotoxicity

Among cases that received NAC > 8 hours post ingestion (n=60)

  • 35% (n=21) developed hepatotoxicity 

Odds of hepatotoxicity

  • 5.5 If NAC initiated > 8 hours post ingestion
  • 3.8 if 4 h post ingestion APAP level >600 mcg/mL  

Conclusion

  • Cohort: no acute liver injury/hepatotoxicity in 76% (n=79)
  • Standard NAC dosing initiated within 8 hours prevented hepatotoxicity in 91% (n=40/44)


Clinical Question:

  • Does dexmedetomidine lead to better short-term and long-term outcomes than propofol in mechanically ventilated adults with sepsis?

Methods:

  • Multicenter (13 US hospitals), double-blinded, 422 mechanically ventilated patients with sepsis
  • Notable exclusion criteria: pregnant, 2nd- or 3rd-degree heart block or persistent bradycardia requiring intervention, indication for bzds, expected to have NMB > 48 hrs, already had received mechanical ventilation >96 hrs
  • Pain was treated with opioid pushes or fentanyl gtt
  • Primary end point: number of calendar days alive without delirium or coma during the 14-day intervention period
    • Secondary efficacy end points included ventilator-free days at 28 days, death at 90 days, and global cognition at 6 months

Results:

  • No sig difference in adjusted number of days alive without delirium or coma over the 14-day intervention period  (dexmedetomidine: 10.7 days vs. propofol: 10.8 days; OR, 0.96; 95% CI, 0.74 to 1.26; P = 0.79
    • No sig differences in the number of ventilator-free days at 28 days, in death at 90 days, or global cognitiion at 6 months
  • Other notable findings:
    • Fewer patients in the dexmedetomidine group had ARDS or signs of trial drug withdrawal
    • Fewer patients in the propofol group extubated themselves
    • Open-label propofol received by 13% in the dexmedetomidine group and 8% in the propofol group) and dexmedetomidine (4% in the dexmedetomidine group and 3% in the propofol group)
    • Rescue midazolam was used in about half the patients, most often for procedural sedation or during NMB, 42% received antipsychotics
    • Similar proportions of patients had organ dysfunction, hypotension, or severe lactic acidosis
    • Symptomatic bradycardia requiring discontinuation of the trial drug was similar in the two groups

Take-home points:

  • Dexmedetomidine or propofol are reasonable options for septic patients requiring mechanical ventilation without notable differences in delirium or mortality

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Home management versus PCP follow-up of patients with distal radius buckle (torus) fractures

 

A recent study investigated outcomes of patients with distal radius buckle fractures who were randomized to

 

  1. Home removal of splint and physician follow-up as needed (home management)  

 

Versus

 

  1. Prescribed PCP follow-up in 1-2 weeks


 

Noninferior study

 

Torus/buckle fractures of the distal radius are the most common fractures in childhood occurring on average in 1 in 25 children

 

This is a stable fracture typically treated with removable wrist splint and very rarely require orthopedic intervention

 

Outcome: functional recovery at 3 weeks

 

Randomized controlled trial at a tertiary care children’s hospital

 

All radiographs reviewed by pediatric radiologist with MSK specialization

 

149 patients. Mean age 9.5 years. 54.4% male

 

Telephone follow-up at 3 and 6 weeks following ED discharge by blinded interviewer

 

Primary outcome was comparison of Activities Scale for Kids-performance scores between groups at 3 weeks

 

Outcomes:  Home management performance score was 95.4% and PCP follow-up group was 95.9%. Mean cost savings were $100.10.

 

Conclusion:  Home management is at least as good as PCP follow-up with respect to functional recovery in ED patients with distal radius buckle fractures.

 

 

 

 

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Category: Neurology

Title: Is There a Seasonal Variation to Bell's Palsy?

Keywords: Bell's palsy, facial palsy, Lyme disease, Borrelia burgdorferi (PubMed Search)

Posted: 2/24/2021 by WanTsu Wendy Chang, MD (Updated: 2/23/2024)
Click here to contact WanTsu Wendy Chang, MD

  • Bell’s palsy can be caused by herpes simplex virus-1 (HIV-1) and Lyme borreliosis.
  • Prior studies have found higher incidence of Bell’s palsy in colder months possibly related to reactivation of latent HSV-1.
  • A recent study looked at the incidence and seasonal variation of positive Lyme tests in Bell’s palsy patients in a Lyme-endemic area (New Jersey).
    • Over a 5-year period, 81% of 442 patients with Bell’s palsy were tested for Lyme and 16% tested positive.
    • The months May through October had a 7.2 times higher incidence of positive Lyme tests in Bell’s palsy patients, with the peak in July.
    • May through October also had a 1.3-fold increased ED visits for Bell’s palsy, also peaking in July.

Bottom Line: In a Lyme-endemic area, the incidence of positive Lyme tests and Bell’s palsy are highest in the Lyme months. This seasonal variation may help guide the management of patients with Bell’s palsy.

 

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Category: Critical Care

Title: The HACOR score to predict intubation need in acute respiratory failure.

Keywords: HACOR, NIV, noninvasive ventilation, acute respiratory failure (PubMed Search)

Posted: 2/2/2021 by Kami Windsor, MD (Emailed: 2/23/2021) (Updated: 2/23/2021)
Click here to contact Kami Windsor, MD

 

BackgroundIn respiratory failure due to COPD and cardiogenic pulmonary edema, noninvasive positive pressure ventilation decreases need for intubation and improves mortality,1 while its utility in other scenarios such as ARDS and pneumonia has yet to be proven.1,2 We know that patients on NIV with delays to needed intubation have a higher mortality,1,3 but intubation and mechanical ventilation come with risks that it is preferable to avoid if possible.

 

So how and when can we determine that NIV is not working?

 

The HACOR (Heart rate, Acidosis, Consciousness, Oxygenation, Respiratory rate) score at 1 hour after NIV initiation has been demonstrated to be highly predictive of NIV failure requiring intubation.4,5 

 

Initial development/validation: Score > 5 after 1 hour of NIV corresponds to >80% risk of NIV failure4

  • Earlier intubation (before 12 hours) in these patients = better survival

External validation: Score > 8 after 1 hour of NIV most predictive of eventual NIV failure 5

  • Average score @ 1-hour of patients with NIV success = 3.8

  • Score remained predictive at 6, 12, 24, 48 hours as well & mortality worsened as delay to intubation time increased 

  • Baseline, pre-NIV score not predictive

  • Better predictive agreement in pneumonia and ARDS

Bottom Line:

  • Patients on NIV require close reassessment to prevent worsened survival due to intubation delay should invasive mechanical ventilation be indicated.

  • A HACOR score >8 after 1 hour of NIV should prompt intubation in most instances, with strong consideration given to a score >5.

 

*Note: ABGs were obtained for PaO2 assessment in the above studies -- the use of SpO2 was not evaluated -- but we are often not obtaining ABGs in our ED patients with acute respiratory failure. The following chart provides an estimated SpO2 to PaO2 conversion.

 

 

WHO 2001

Caveats: 

  1. Pulse oximetry may be inaccurate in darker skin tones (overestimated by ~2%)6 and in certain disease processes (e.g. CO poisoning, profound shock states, etc.)
  2. The oxyhemoglobin dissociation curve shifts right with increasing pCO2/decreasing pH (lower saturation for a given PaO2).

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Category: Pediatrics

Title: Is there utility in measuring BNP in pediatric patients in the emergency room?

Keywords: Congestive heart failure, trouble breathing, basic natriuretic peptide (PubMed Search)

Posted: 2/19/2021 by Jenny Guyther, MD (Updated: 2/23/2024)
Click here to contact Jenny Guyther, MD

In children with known congenital heart disease, BNP measurements are higher in those patients with heart failure compared to those without heart failure.

The utility of BNP in differentiating a cardiac from pulmonary pathology in patients with respiratory distress has been studied in pediatrics. In one study involving 49 infants with respiratory distress, the patients with a final diagnosis of heart failure had a higher mean BNP concentration than those patients with other causes.  Also, there is a suggestion that the relative change in NT proBNP levels may be useful in patients with underlying pulmonary hypertension.  However, currently there is not enough literature to support the routine use of BNP or NT proBNP in acute management.

Bottom line: BNP can be useful in your patient with congenital heart disease who is decompensating and may be used in a patient where there is difficulty in differentiating a primary respiratory from cardiac etiology.

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Category: Toxicology

Title: Haloperidol vs. ondansetron for cannabis hyperemesis syndrome

Keywords: Haloperidol, ondansetron, cannabis hyperemesis syndrome (PubMed Search)

Posted: 2/18/2021 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

 

Patients with cannabis hyperemesis syndrome experience recurrent/protracted nausea/vomiting. Cases of cannabis hyperemesis syndrome may increase as cannabis use becomes more common in the United States.

A randomized control trial (triple-blind) was conducted to compare haloperidol (0.05 or 0.1 mg/kg) IV or ondansetron 8 mg IV. Primary outcome was reduction of abdominal pain and nausea from baseline (on a 10 cm visual analog scale) 2 hours after treatment.

Results

  • 33 subjected were randomized to haloperidol (n=13) and ondansetron (n=17)
  • 30 used 1.5 gm/day since 19 years of age.
  • Haloperidol was superior to ondansetron
    • 2.3 cm difference in pain and nausea
    • Less use of rescue antiemetics (31% vs. 59%)
    • Shorter time to ED departure (3.1 hours vs. 5.6 hours)

Conclusion

  • In this small trial, haloperidol (0.05 or 0.1 mg/kg IV) was superior to ondansetron (8 mg IV) in the treatment of acute cannabis associated hyperemesis  

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Category: Orthopedics

Title: What time of day is best for exercise to achieve weight loss goals?

Keywords: diabetes, exercise, weight loss (PubMed Search)

Posted: 2/13/2021 by Brian Corwell, MD (Updated: 2/23/2024)
Click here to contact Brian Corwell, MD

What time of day is best for exercise to achieve weight loss goals?

 

Working out in the morning has traditionally held the edge, especially if done on an empty stomach.

Upon walking, elevated levels of cortisol and GH will aid in fat metabolism.

Switching to a morning workout may also decrease appetite throughout the day.

Morning exercise may also induce significant circadian phase?shifting effects. Patients report feeling more alert in the morning and get more tired at night. This may “force” people to get increased rest as poor sleep quality and duration has been associated with weight gain. 

Moderate intensity aerobic exercise has been shown to cause immediate mood improvement and mental productivity. These effects can last up to 12 hours and may be a simple aid to combat job stress.

However, a recent small study looked at this question with a group of men at high risk for Type 2 diabetes.

Those that exercised in the morning had better blood sugar control and lost more abdominal fat than those who exercised in the morning.

Study:  32 adult males (58 ± 7 years) at risk for or diagnosed with type 2 diabetes performed 12 weeks of supervised exercise training either:

In the morning (8.00–10.00 a.m., N = 12) OR

In the afternoon (3.00–6.00 p.m., N = 20)

Test: Graded cycling test with ECG monitoring until exhaustion

Results:  Compared to those who trained in the morning, participants who trained in the afternoon experienced superior beneficial effects of exercise training on peripheral insulin sensitivity, insulin?mediated suppression of adipose tissue lipolysis, fasting plasma glucose levels, exercise performance and fat mass.

Conclusion:  Metabolically compromised patients may benefit from shifting their exercise routine to the afternoon from the morning. Ultimately, any exercise is great in this population, but this study may be worth sharing to your patients.

 

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Category: Critical Care

Title: HOT-ICU

Keywords: Oxygenation, Mechanical Ventilation, Critical Care (PubMed Search)

Posted: 2/9/2021 by Mark Sutherland, MD
Click here to contact Mark Sutherland, MD

Optimal oxygenation targets and the possible, theoretical, benefits of hyperoxygenating critically ill patients have long been points of controversy.  Multiple studies have suggested harm in pursuing aggressive hyperoxygenation amongst critical patients with various conditions ranging from myocardial infarction to sepsis to neurologic conditions.  In addition, oxygen toxicity is a known mechanism causing ARDS.

The HOT-ICU trial adds to the list of arguments against hyperoxygenation, by looking at 2928 ICU patients on high levels of supplemental oxygen and targeting a paO2 of 60 mm Hg (low oxygen group) vs paO2 of 90 mm Hg (high oxygen group).  There was no difference in mortality, or other significant difference in outcomes.

 

Bottom Line: A lower paO2 goal of 60 (correlates to an O2 sat of 90%) is noninferior to a higher paO2 goal of 90 (O2 sat of approximately 96%).  When titrating oxygen, targeting a pulse ox of 90-96% is reasonable in critically ill patients.  Be sure to include an upper limit on the sat goal, beware an O2 sat of 100%, and titrate down supplemental oxygen when the spO2 is above goal, as the paO2 may be dangerously high.

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