Category: Critical Care
Keywords: Calcium, Cardiac Arrest, ACLS, Code Blue (PubMed Search)
Posted: 1/5/2022 by Mark Sutherland, MD
Click here to contact Mark Sutherland, MD
There are several well known medications that we tend to give by default during cardiac arrests. It seems like for each of them, every few years someone does an RCT to see if they really help anybody, and we're all disappointed by what they find. Well... prepare to be disappointed again, I'm afraid.
These Danish authors randomized 391 patients in cardiac arrest to either calcium or saline (given IV or IO). They gave 2 doses of either calcium chloride or saline, with the first dose being along with the first epi dose. Primary outcome was ROSC. They also looked at modified Rankin at 30 and 90 days.
The trial was stopped early for harm. Now, we all know the dangers of interpreting studies that were stopped early, but this doesn't look great for calcium. 19% of the calcium group had ROSC compared to 27% of the saline group (p = 0.09). Percentage of patients alive, and with favorable mRS at 30 days also both favored the saline group (although also not statistically significantly). By the way, of the patients who had calcium levels sent, 74% in the calcium group, vs 2% in the saline group, were hypercalcemic. Whether that had anything to do with the outcome, we may never know.
Bottom Line: Is this saying that calcium hurts patients in cardiac arrest? Maybe... but I don't think this is high quality enough data to draw that conclusion. At the very least, however, just giving everyone in arrest calcium is probably not terribly helpful. If you have a reason to give it (known severe hypocalcemia, recent parathyroid surgery, suspected hyperkalemia, etc) then go for it, otherwise you can probably focus your resus on more important things.
Vallentin MF, Granfeldt A, Meilandt C, et al. Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2021;326(22):2268–2276. doi:10.1001/jama.2021.20929
Category: Pediatrics
Posted: 12/31/2021 by Rose Chasm, MD
Click here to contact Rose Chasm, MD
Benary, Lozano, Higley, Lowe. Pediatrics. Ondansteron Prescription is Associated with Reduced Return Visits to the Pediatric Emergency Department for Children with Gastroenteritis. 76,5. November 2020.
Rivera-Dominguez, Ward. StatPearls. Pediatric Gastroenteritis. April 2021.
Managing Acute Gastroenteritis Among Children. CDC. MMWR.
Category: Critical Care
Posted: 12/28/2021 by Mike Winters, MBA, MD
Click here to contact Mike Winters, MBA, MD
The BOUGIE Trial
Driver BE, et al. Effect of use of a bougie vs endotracheal tube with stylet on successful intubation on the first attempt among critically ill patients undergoing tracheal intubation. JAMA. 2021. Published online December 8, 2021
Category: Airway Management
Keywords: Caffeine, Exercise, VO2 max (PubMed Search)
Posted: 12/25/2021 by Brian Corwell, MD
Click here to contact Brian Corwell, MD
Caffeine is probably the most wildly used and studied drug/supplement in the world.
It has been shown to enhance exercise capacity and performance.
Mechanism of action is likely multifactorial and involves adenosine receptor antagonism via direct CNS action improving mental alertness, reaction time and reducing the perceived exertion rate (pain).
To no surprise, amateur and elite athletes use caffeine to improve performance.
The well-accepted dosage of caffeine to improve performance is between 3 and 6 mg/kg, approximately 60 min before exercise. This dosage promotes (between 1 and 8%) performance gains in aerobic exercises and exercises with high glycolytic demand from cyclists to tennis players to weightlifters.
Consider the lower end of this range if interested in trying this on your own.
In an evaluation of 20,686 urine samples of elite athletes, almost 75% of the samples contained caffeine in concentrations higher than 0.1 μg/mL
Caffeine also increases maximal oxygen uptake (VO2 max)
23 elite athletes were tested twice with and twice without caffeine.
Randomized, double-blinded, placebo-controlled study.
Caffeine 4.5 mg/kg taken 45 minutes before exercise
Measures: Time to exhaustion and VO2 max.
Caffeine increased time to exhaustion and VO2 max, thereby increasing overall performance.
If you are going to incorporate using caffeine before your next workout, I suggest espresso shots for extra caffeine without the volume of a large cup of coffee. Beware of known side effects such as jitters, anxiousness and difficulties with sleep if taken later in the day. Also consider stomach upset digestive issues, and increased heart rate.
Happy Holidays!!!!
Category: Toxicology
Keywords: xylazine, adulterate, heroin, fentanyl (PubMed Search)
Posted: 12/16/2021 by Hong Kim, MD
(Emailed: 12/23/2021)
Click here to contact Hong Kim, MD
Xylazine is a central alpha-2 agonist (similar to clonidine) that is used as a veterinary tranquilizer. It also possesses analgesic, and muscle relaxant properties. Heroin/fentanyl is increasingly being adulterated with xylazine and resulting in severe adverse effects (CNS and respiratory depression, bradycardia, and hypotension), including deaths.
According to CDC, 0.1%-5.5% of IMF death in US between 2019 – 2020 involved xylazine.
In Philadelphia, PA:
The detection of xylazine in unintentional overdose death increased from
Approximately 25% of drug seizures in Philadelphia contained xylazine in 2019
There is no effective pharmacologic agent for xylazine toxicity. Similar to clonidine toxicity, high dose naloxone may be tried. But pediatric data show that approximately 50% of pediatric clonidine toxicity response to high-dose naloxone administration. Thus, naloxone administration may not reverse the CNS/respiratory depression, bradycardia and hypotension.
Conclusion
O’Donnell J, Tanz LJ, Gladden RM, Davis NL, Bitting J. Trends in and Characteristics of Drug Overdose Deaths Involving Illicitly Manufactured Fentanyls — United States, 2019–2020. MMWR Morb Mortal Wkly Rep 2021;70:1740-1746. DOI: http://dx.doi.org/10.15585/mmwr.mm7050e3external icon.
Johnson J, et al. Inj Prev 2021;27:395–398. doi:10.1136/injuryprev-2020-043968
Category: Critical Care
Keywords: bacterial infection, sepsis, Emergency Department, broad spectrum antibiotics (PubMed Search)
Posted: 12/14/2021 by Quincy Tran, MD, PhD
(Updated: 10/6/2024)
Click here to contact Quincy Tran, MD, PhD
When we initiate the sepsis bundle in the ED for patients with suspected sepsis, what probability that those patients who received broad spectrum antibiotics in the ED would have bacterial infection.
This study (Shappell et al) provides us with a glimpse of those number.
Settings: Retrospective study of adults presenting to 4 EDs in Massachusetts.
Patients: patients with suspected serious bacterial infection in ED, defined as blood cultures and initiation of at least one broad spectrum antibiotics. Random selection of 75 patients per hospital.
Patients were categorized in 4 groups:
Outcome: Prevalence of each category.
Study Results: 300 patients who received broad spectrum antibiotics.
3. For patients who were admitted to the ICU (P = 0.26)
a. Definite 16.5%
b. Likely 8.6%
c. Unlikely 16.4%
d. Definitely no 20.4%
4. Source of infection
Discussion:
Conclusion:
Approximately 30% of patients who had blood cultures drawn and received broad spectrum antibiotics in ED have low likelihood of bacterial infection.
Reference:
1. Shappell CN, Klompas M, Ochoa A, Rhee C; CDC Prevention Epicenters Program. Likelihood of Bacterial Infection in Patients Treated With Broad-Spectrum IV Antibiotics in the Emergency Department. Crit Care Med. 2021 Nov 1;49(11):e1144-e1150. doi: 10.1097/CCM.0000000000005090. PMID: 33967206; PMCID: PMC8516665.
2. Klein Klouwenberg PM, Cremer OL, van Vught LA, Ong DS, Frencken JF, Schultz MJ, Bonten MJ, van der Poll T. Likelihood of infection in patients with presumed sepsis at the time of intensive care unit admission: a cohort study. Crit Care. 2015 Sep 7;19(1):319. doi: 10.1186/s13054-015-1035-1. PMID: 26346055; PMCID: PMC4562354.
Category: Critical Care
Posted: 12/7/2021 by Caleb Chan, MD
Click here to contact Caleb Chan, MD
Clinical Pearls for Variceal Hemorrhage
-lower mortality with “restrictive” (Hgb 7-9 g/dL) rather than liberal strategy
-antibiotic “prophylaxis” reduces mortality
-no need to correct INR with FFP
-vasoactives (i.e. octreotide, somatostatin, terlipressin) alone may actually control bleeding
-for your ICU boarders...if persistent or severe rebleeding (despite endoscopic therapy), rescue TIPS is therapy of choice (call IR)
Zanetto A, Shalaby S, Feltracco P, et al. Recent advances in the management of acute variceal hemorrhage. Journal of Clinical Medicine. 2021;10(17):3818.
Category: Pharmacology & Therapeutics
Keywords: Calcium, cardiac arrest (PubMed Search)
Posted: 12/4/2021 by Ashley Martinelli
(Updated: 10/6/2024)
Click here to contact Ashley Martinelli
Calcium is commonly administered during cardiac arrest, but there is little data to support or refute its use. The Calcium for Out-of-Hospital Cardiac Arrest trial was a randomized, double-blind, placebo-controlled parallel group study conducted in Denmark. Their EMS system responds to all cardiac arrests with an ambulance and a physician-manned mobile emergency care unit.
Adult patients were included if they had out of-of-hospital (OOH) cardiac arrest and received at least 1 dose of epinephrine. Exclusion criteria were traumatic arrest, known or suspected pregnancy, prior enrollment in the trial, receipt of epinephrine from an EMS unit not in the trial, or a clinical indication for calcium during the arrest (i.e. hyperkalemia or hypocalcemia).
Patients received 735mg calcium chloride dihydrate (5 mmol CaCl –US standard product is 1000mg) or saline control immediately after the first dose of epinephrine. A second dose was administered after the second dose of epinephrine if cardiac arrest ongoing. Teams were blinded to the treatments. The primary outcome was ROSC for at least 20 minutes.
397 patients were randomized (197 calcium, 200 saline). The average age was 68 years old, 70% were male, and over 80% of the cardiac arrests occurred at home, 60% witnessed arrests, and 82% received bystander CPR. Only 25% were in a shockable rhythm. The time to first epinephrine and study drug was approximately 17 minutes and over 70% received two doses.
ROSC rates were low and not statistically different between groups, 19% in the calcium group vs 27% in the saline group. There was no difference in survival to 30d or neurologic function. In the patients who did achieve ROSC in the calcium arm, 74% had hypercalcemia.
Bottom Line: The routine use of calcium in out-of-hospital cardiac arrest is not recommended.
Vallentin MF, et al. Effect of intravenous or intraosseous calcium vs saline on return of spontaneous circulation in adults with out-of-hospital cardiac arrest. JAMA. Published online November 30, 2021. doi:10.1001/jama.2021.20929
Category: Pediatrics
Keywords: peds ortho, calcaneus, stress injury (PubMed Search)
Posted: 12/3/2021 by Rachel Wiltjer, DO
Click here to contact Rachel Wiltjer, DO
Sever Disease
Smith JM, Varacallo M. Sever Disease. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441928/
Category: Orthopedics
Keywords: Elbow, fracture, radiology (PubMed Search)
Posted: 11/27/2021 by Brian Corwell, MD
(Updated: 10/6/2024)
Click here to contact Brian Corwell, MD
Presentations of Fracture in Nursemaids Elbow
Study group: Visits by children younger than 10 years, with a diagnosis of radial head subluxation at 1 of 45 pediatric EDs from 2010 to 2018.
Retrospective cohort study of 88,466 ED visits for radial head subluxation
Outcome: Missed fracture (return visit for upper extremity fracture within 7 days of the index visit).
Results
Median patient age was 2.1 years,
59% of visits were by female patients,
60% of cases occurred in the left arm.
Radiography was performed at 28.5% of visits (Range 19.8% to 41.7%.)
Extremity fractures were observed in 247 cases, representing 0.3% of the cohort.
The odds of missed fracture were higher in:
Summary:
Only 0.3% of children with a diagnosis of radial head subluxation subsequently received a diagnosis of an upper extremity fracture within 7 days of the index visit.
Missed fractures were commonly about the elbow such as a supracondylar fracture. However, this study also found a significant proportion of missed fractures in other locations (e.g. shoulder, wrist), highlighting the importance of a careful physical examination, and the limitations of localizing pain in younger children.
Recurrence was common, and the risk of recurrence decreased with increasing age at first presentation. Overall, radial head subluxation recurrence was 8.7% after the first visit VERSUS 12%-13% in children younger than 2 years. THese patients are likely to return to the ED with a recurrence within 2 years. These findings should help inform anticipatory guidance to parents regarding the risk of recurrence based on their child’s age.
Category: Critical Care
Posted: 11/23/2021 by Duyen Tran, MD
(Updated: 10/6/2024)
Click here to contact Duyen Tran, MD
Myocarditis is a potentially fatal inflammatory disorder of the heart. Viral infection is the most common cause but can also result from toxic, autoimmune, or other infectious etiologies. Complications include life-threatening dysrhythmias, heart failure, and fulminant myocarditis. Typically affects young patients (20-50 years old).
ED management pearls
Gottlieb, Michael et al. "Diagnosis And Management Of Myocarditis: An Evidence-Based Review For The Emergency Medicine Clinician". The Journal Of Emergency Medicine, vol 61, no. 3, 2021, pp. 222-233.
Category: Pediatrics
Keywords: orthopedics, upper extremity fractures, playgrounds (PubMed Search)
Posted: 11/19/2021 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD
Curnow H and Millar R. Too far to fall: Exploring the relationship between playground equipment and paediatric upper limb fractures. Journal of Pediatrics and Child Health. 2021.
Category: Critical Care
Keywords: OHCA, IHCA, targeted temperature management, therapeutic hypothermia, postcardiac arrest (PubMed Search)
Posted: 11/16/2021 by Kami Windsor, MD
Click here to contact Kami Windsor, MD
Fever has long been understood to be associated with worse outcomes in patients post-cardiac arrest. Whether ascribing to the goal of 33-34°C, 36°C, or simply <38°C, close monitoring and management of core temperatures are a tenet of post-cardiac arrest care.
A recently published study compared the effectiveness of several methods in maintaining temperatures <38°C…
Results:
Maintenance of temp <38°C:
Mean change in temp from baseline:
Limitations:
Bottom Line:
Category: Orthopedics
Keywords: Elbow, dislocation, instability (PubMed Search)
Posted: 11/13/2021 by Brian Corwell, MD
(Updated: 10/6/2024)
Click here to contact Brian Corwell, MD
The classic mechanism for nursemaids elbow is axial traction on a pronated forearm and extended elbow.
The force allows a portion of the annular ligament to slip over the radius.
Consider this diagnosis with other mechanisms of injury especially if the exam is not suggestive of fracture.
Suspect in a patient in minimal distress with arm held semi flexed and pronated.
A recent retrospective study looked at other mechanisms of injury.
69 subjects with a median age of 2.5 years
The most common mechanisms of injury were fall (57%), direct hit to the elbow (16%), and rolling over (7%).
Some studies note the left elbow is more commonly involved but this is likely due to most guardians being right-handed, thereby holding the child’s left hand
Li N, Khoo B, Brown L, Young T. Nonaxial Traction Mechanisms of Nursemaid's Elbow. Pediatr Emerg Care. 2021 Jun 1;37(6)
Category: Neurology
Keywords: drug reaction, toxicity, neurotoxicity, antibiotics (PubMed Search)
Posted: 11/10/2021 by WanTsu Wendy Chang, MD
(Emailed: 11/11/2021)
Click here to contact WanTsu Wendy Chang, MD
Bottom Line: Recognition of antibiotic associated neurotoxicity reduces unnecessary workup and serious adverse effects.
Follow me on Twitter @EM_NCC
Category: Critical Care
Keywords: Hypothermia, Cardiac Arrest, TTM (PubMed Search)
Posted: 11/9/2021 by Mark Sutherland, MD
Click here to contact Mark Sutherland, MD
The debate around post-arrest management recently has revolved around whether therapeutic hypothermia should go cold, or LESS cold. But what if we went MORE cold? While recent TTM trials have compared temps such as 33 to 36 and 33 to 37.5 or less, a recent trial called CAPITAL CHILL looked at 34C vs 31C. There is a solid physiologic basis for cooling post-arrest patients, so do they do better if we lower their temp even further? Maybe we're not going cold enough with 33?
Bottom Line: No, 31C is not better than 34C for post-arrest patients. This study compared death and poor neurologic outcome at 180 days with 31 and 34C targets for post-arrest patients, and found no difference (in fact the 31C group did slightly, but not significantly, worse on the primary outcome, and worse on a few secondary outcomes).
While debate remains for 33 vs 36 vs afebrile, the literature does not currently support consideration of temps below 33.
Le May M, Osborne C, Russo J, So D, Chong AY, Dick A, Froeschl M, Glover C, Hibbert B, Marquis JF, De Roock S, Labinaz M, Bernick J, Marshall S, Maze R, Wells G. Effect of Moderate vs Mild Therapeutic Hypothermia on Mortality and Neurologic Outcomes in Comatose Survivors of Out-of-Hospital Cardiac Arrest: The CAPITAL CHILL Randomized Clinical Trial. JAMA. 2021 Oct 19;326(15):1494-1503. doi: 10.1001/jama.2021.15703. PMID: 34665203; PMCID: PMC8527358.
Category: Pharmacology & Therapeutics
Keywords: Kcentra, AC Reversal, Anticoagulant (PubMed Search)
Posted: 11/6/2021 by Wesley Oliver
Click here to contact Wesley Oliver
Kcentra (four-factor prothrombin complex concentrate, 4f-PCC) is approved for the reversal of warfarin using a weight-based dosing strategy based on INR. However, since the approval of Kcentra, data has shown a fixed-dose strategy and use for direct-acting oral anticoagulants (DOAC) is appropriate. There are even recommendations to use a fixed-dose for DOACs in some situations. Utilizing a fixed-dose strategy can help with decreasing drug preparation/delivery times and costs.
Our institution now only uses a weight-based Kcentra dose of 50 units/kg for patients on DOACs with ICH or trauma-induced coagulopathy. All other patients receive a fixed-dose of Kcentra 1,500 units or 2,000 units based on anticoagulant and other criteria.
Below is a diagram summarizing our current dosing strategy for Kcentra at our institution.
ICH=intracerebral hemorrhage
DOAC=direct-acting oral anticoagulant (rivaroxaban, apixaban, and edoxaban)
Other points of interest at our institution:
Kcentra® [package insert]. CSL Behring, Marburg, Germany; 2013.
https://labeling.cslbehring.com/PI/US/Kcentra/EN/Kcentra-Prescribing-Information.pdf
Tomaselli GF, et al. 2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2020 Aug 4;76(5):594-622.
University of Maryland Medical Center. 2021. Pre- and Peri-Procedural Management of Anticoagulation, Management of Bleeding in the Setting of Anticoagulation, Intracranial Hemorrhage, and Dilutional Coagulopathies. Internal guideline.
Category: Pediatrics
Keywords: T1DM, DKA, pediatrics (PubMed Search)
Posted: 11/5/2021 by Natasha Smith, MD
Click here to contact Natasha Smith, MD
Incidence of T1DM is 1.93/1000 of youth <20 years old in the United States, with a bimodal distribution of onset. Onset peaks from ages 4-6 and again at puberty.
Prior to the development of DKA, diabetes often has an insidious onset with symptoms of polydipsia, polyphagia and polyuria with weight loss in children. It can also be asymptomatic.
When DKA is present, symptoms will include neurological manifestations (confusion, lethargy), GI symptoms (abdominal pain, nausea, vomiting), or respiratory abnormalities (Kussmaul respirations.) Polyuria and polydipsia are frequently present as well.
Diagnosis of DKA includes: serum glucose of >200 mg/dL, serum or urine ketones, and a pH <7.30 or bicarbonate <15 mEq/L.
DKA is classified as mild, moderate or severe:
Mild: pH 7.21-7.30, HCO3 11-15 mEq/L
Moderate: pH 7.11-7.20, HCO3 6-10 mEq/L
Severe: pH < 7.10, HCO3 <5 mEq/L
Initial treatment is 10 ml/kg of isotonic fluid bolus to a max of 500 ml, then reassess. Continue to replace fluids gradually to cover maintenance fluids as well as to treat dehydration. Do NOT bolus insulin. Rather, start a drip at 0.05-0.1 units/kg/hr. Continue insulin until acidosis has completely resolved. Once the serum glucose falls below 250 mg/dL, start dextrose to prevent hypoglycemia until the gap closes.
Cerebral edema can develop 4-12 hours after treatment has been initiated. Observe for change in mental status, posturing, decreased response to pain, cranial nerve palsy, bradycardia, or abnormal respiratory pattern. This is a clinical diagnosis! Although a head CT can be obtained, it is often negative and treatment with mannitol or hypertonic saline should be started as soon as there are clinical changes.
DKA has resolved when pH > 7.3 and HCO3 is >15.
Naga, O. (2020). Pediatric Board Sudy Guide: A Last Minute Review, 2nd Edition. Springer Nature Switzerland AG.
Dean, T. and Bell L. (2019). Nelson Pediatrics Board Review Certification and Recertification. Elsevier.
Category: Toxicology
Keywords: pediatric fatality, poisoning, US (PubMed Search)
Posted: 11/4/2021 by Hong Kim, MD
Click here to contact Hong Kim, MD
Substance use disorder contributes significantly to pediatric exposure/poisoning. There has been an increase in the opioid overdose deaths in the US, placing pediatric population to possible exposure. A retrospective study of fatal pediatric poisoning in the US was investigated using the National Violent Death Reporting System (NVDRS) from 2012-2017.
17 US states (AK, CO, GA, KT, MD, MA, NJ, NM, NC, OH, OK, OR, RI, SC, UT, VA, WI) reported to NVDRS from 2012-2017.
Age was limited to 0-9 years
Results
1850 violent deaths were identified: n=122 (7%) were poisoning related
Characteristics
Region
Most common exposure/etiology
Conclusion
Hunter AA et a. An examination of fatal child poisonings in the United States using the National Violent Death Reporting System (NVDRS), 2012–2017. Clin Toxicol. 2021
Category: Critical Care
Posted: 11/2/2021 by Mike Winters, MBA, MD
(Updated: 10/6/2024)
Click here to contact Mike Winters, MBA, MD
Initial Mechanical Ventilation Settings for the Intubated Asthmatic
Long B, et al. Evaluation and management of the critically ill adult asthmatic in the emergency department setting. Am J Emerg Med. 2021;44:441-51.