Childhood vaccination has significantly decreased the incidence of bacterial meningitis and bacteremia in infants and young children, specifically vaccines against H. influenzae and S. pneumoniae, shifting broad workups for these disease and empiric antibiosis to younger age groups as rates declined. In recent years the percentage of unvaccinated and under-vaccinated children has been rising due to multiple factors; now over 1% of children in the US under 2 years of age are unvaccinated. The question becomes, should these children be treated more similarly to young infants as they lack to immunity to these organisms?

Literature on this topic is sparse, although, Finkel, Ospina-Jimenez, et al. reviewed the literature available and proposed an algorithm for well appearing children 3-24 months of age without a clear source and a temperature of >39C (102.2F). Recommendations included UA (to determine possible source) in the following patients: fever > 2 days, prior UTI, female or uncircumcised male <12 months, or male <6 months. They also recommended evaluation with viral panel. If no source was determined, they then recommended CBC and procalcitonin with a CXR for WBC > 20,000/mm³. For WBC >15,000/mm³, ANC >10,000/mm³, absolute band count >1,500/mm³, or procalcitonin >0.5ng/mL they recommended blood culture, ceftriaxone 50 mg/kg, and follow up within 24 hours.

Bottom line: Literature is scarce and practice patterns are likely to evolve as ramifications of decrease in vaccination rates become clearer. The above algorithm is proposed, however covers limited situations and may not be practical in all settings. Clinical judgement should be used in the evaluation and management of these patients. A more conservative approach compared to vaccinated infants is reasonable at this time.

 

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Transcutaneous Cardiac Pacing

• Transcutaneous cardiac pacing (TCP) is often attempted while preparing for transvenous cardiac pacing in critically ill patients with symptomatic bradycardia unresponsive to medical therapy.
• For TCP, pacer pads can be placed in either the anterolateral (AL) or anteroposterior (AP) positions.  
• Current resuscitation guidelines from the American Heart Association and the European Resuscitation Council do not identify a preferred pacer pad placement for TCP.
• In a recent study of patients who received TCP following cardioversion from atrial fibrillation or flutter, Moayedi and colleagues found that pacer pads placed in the AP position required less mA to capture and chest wall contractions were less severe when compared to the AL position.
• In fact, capture was approximately 80% more likely with pacer pads placed in the AP position compared to the AL position.
• Take Home Point: Consider placing the pacer pads in the AP position the next time you need to initiate TCP.

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This study found that 22% of Americans do not have access to a trauma center within 60 minutes. Eight percent of the population relied on Level III centers.  Not unexpectantly, Black and Native Americans were overly represented in the group receiveing care at Level III centers. White and Native Americans were over represented in the group without access to trauma care within 60 minutes. Most disappointing of all, none of this has changed since 2010. Some states have a robust trauma network, while others need to evaluate their needs and potentially add Level III centers to cut down the time to trauma care.  What is your area's trauma coverage and what level?

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Dog ownership has become more common especially during the pandemic.

Almost 70% of US households own a pet and almost half own ≥1 dogs.

There are many health benefits associated with dog ownership including: reduced risk of asthma and allergic rhinitis in children exposed to pets during early ages, improvement in symptoms of PTSD, overall wellbeing & alleviation of social isolation in elderly individuals and increased physical activity.

The main positive impact of dog ownership seems to be in relation to cardiovascular risk including an association with lower blood pressure levels, improved lipid profile, and diminished sympathetic responses to stress.

Study:  A systematic review and meta-analysis (10 studies, over 3 million participants) to evaluate the association of dog ownership with all-cause mortality, with and without prior cardiovascular disease, and cardiovascular mortality. Mean follow up 10 years.

Results: Dog ownership was associated with a 24% risk reduction for all-cause mortality as compared to non-ownership (relative risk, 0.76; 95% CI, 0.67–0.86) with 6 studies demonstrating significant reduction in the risk of death.

In individuals with prior coronary events, dog ownership was associated with an even more pronounced risk reduction for all-cause mortality (relative risk, 0.35; 95% CI, 0.17–0.69). When authors restricted the analyses to studies evaluating cardiovascular mortality, dog ownership conferred a 31% risk reduction for cardiovascular death (relative risk, 0.69; 95% CI, 0.67–0.71).

The cause of this benefit is unclear. Though some activities such as the act of petting a dog has been observed to lower blood pressure levels, the mechanism for the longer survival is likely through enhanced physical activity provided by dog walking.

Conclusion:  Dog ownership is associated with reduced all-cause mortality likely driven by a reduction in cardiovascular mortality. Dog ownership as a lifestyle intervention may offer significant health benefits, particularly in populations at high-risk for cardiovascular death.

Finally, meet Winston, a French bulldog who, last night, won the National Dog Show!

https://static.onecms.io/wp-content/uploads/sites/47/2022/11/22/national-dog-show-winner-french-bulldog-winston-2022-2000.jpg

 

This small study looked at patients with penetrating neck injuries and tried to determine in those with "hard signs" of injury (hemorrhage, expanding hematoma, or ischemia)  if they required immediate operative managment.  The authors concluded:

"Although hard signs in PCVIs are associated with the need for operative intervention, initial CT imaging can facilitate endovascular options or nonoperative management in a significant subgroup. Hard signs should not be considered an absolute indication for immediate surgical exploration."

This is a small study and it is unclear why some patients went to CT vs directly to the operating room. This may not be a practice changing study, but it may validate provider gestalt of CT vs direct to operating room. We can add this to the growing body of evidence that CT scanning in penetrating trauma can be used to diffrentiate who needs emergent operative intervention vs. endovascular therapy vs close observation. This study certainly opens the door for further reaserch in the area of management of penetratign neck injuries. 

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This was a cross-sectional survey for the Diversity-Related Research Committee of the Women in Critical Care (WICC) Interest Group of the American Thoracic Society.

 

Settings: 62 sites in Canada and the US

Participants: Attending physicians who worked in ICUs

Questionaire:

·         Measure of Moral Distress for healthcare professionals (27 items),

·         Maslach burnout inventory (2 items),

·         Stanford Professional Fulfilment Index (14-items), Brief Cope scale (14-items)

Study Results:

1.       Demographics:

·         431 participants (approximately 43.3% response rate).

·         334 (65%) participants worked at University-affiliated hospitals

·         387 (89.0%) worked in Adult ICUs.

·         Pre-pandemic, clinical days/months was 10.1 (± 14) days, and increased to 13.1 (± 16) days during the pandemic.

2.       Measure of moral distress: Average score 95.6 ± 66.9 (maximum 417).

·         The highest score (mean 8.5 ± 4.8), for distress, came from the item: “Follow the family insistence to continue aggressive treatment even though it is not in the best interest of the patient.” ((Family wanted to do everything).

3.       Stanford Fulfillment Index:

·         387 (91.9%) intensivists found their work meaningful and 365 (86.5%) felt worthwhile at work, although most felt physically (297, 71.6%), emotionally (266 [63.8%]) exhausted.

4.       Coping strategies:

·         Participants resorted to a wide variety of scoping strategies ranging from Acceptance (90%), Self-distraction (85%) to Substance abuse (32%) and Denial (18%).

·         Most physicians (231 [55.9%]) reported that their coping remained the same before and during the pandemic.

Discussion:

·         Physicians are quite resilient. The authors found that physicians who worked more days experienced significantly more moral distress but with similar Stanford Professional Fulfillment score.

·         This finding was similar to an exploratory analysis from a meta-analysis that showed physicians, among other healthcare workers, were less likely to have severe symptoms of PTSD (2).

·         Women and physicians who were persons of color experienced significantly higher moral distress and burn-out.

Conclusion:

There was moderate moral distress and burn-out, although physicians who worked in ICUs still achieved moderate professional fulfillment.  Up to 20% of ICU physicians used a maladaptive coping strategy

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Opioids & NSAIDs for MSK pain in the ED:  Effectiveness and Harms

 

Study selection:  A recent systematic review in Annals of Internal Medicine attempted to evaluate the effectiveness and harms of opioids for musculoskeletal pain in the emergency department.

Included were RCTs of any opioid analgesic as compared with placebo or a nonopioid analgesic.

Conditions studied:  bone injuries, soft tissue injuries, spinal pain, and mixed presentations.

Out of 2464 articles, they included 42 trials (n=6128).

Effectiveness data:  Opioids were statistically but not clinically more effective in reducing pain in the short term (approximately 2 hours) versus placebo and Tylenol but were not clinically or statistically more effective than NSAIDs.

 

Take home: Opioids and NSAIDs may have about the same pain outcomes.

 

Harm data:  The results on harms were very mixed. Overall, there were fewer harms with NSAIDs than opioids. However, many studies showed less of a difference. The benefit with NSAIDs due to fewer harms may be less in patients with mixed musculoskeletal conditions.

Opioids may carry higher risk for harms than placebo, Tylenol, or NSAIDs. Authors also found that an increased opioid dose may increase harms from opioids.

Limitations: Limited data on long-term outcomes and longer-term pain management

 

 

 

 

 

 

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DOSE VF (DOuble SEquential External Defibrillation for Refractory VF) Trial 

Background - High quality data regarding the use of double sequential external defibrillation (DSED) and vector-change (VC) defibrillation in refractory vfib is limited

Study

-Three-group, cluster-randomized, controlled trial in six Canadian paramedic services

-Study population: 

-OHCA with refractory vfib (initial presenting rhythm of vfib or pulseless VT that was still present after three consecutive rhythm analyses and standard defibrillations separated by 2 minute intervals of CPR) of presumed cardiac etiology (405 patients)

-Some notable exclusion criteria: 

-suspected drug overdose, hypothermia, traumatic cardiac arrest

-Protocol:

-First 3 defib attempts in the standard (anterior-lateral) position

-If remained in vfib after three consecutive shocks randomized to one of:

1. Standard defib for all subsequent attempts (136 pts)

2. VC defib (all subsequent attempts in anterior-posterior position) (144 pts)

3. DSED (applied second set of pads in AP position) with near simultaneously (<1 sec) defib shocks (125 pts)

Results

-Primary outcome: survival to hospital discharge

-38 patients (30.4%) in the DSED group vs. 18 (13.3%) in the standard group (RR 2.21; 95% CI, 1.33 to 3.67) (Fragility index of 9)

-31 patients (21.7%)  in the VC group (RR [vs. standard], 1.71; 95% CI, 1.01 to 2.88) (Fragility index of 1)

-Notable secondary outcome: survival with a good neurologic outcome

-34 patients (27.4%) who received DSED vs. 15 patients (11.2%)  with standard defibrillation (RR, 2.21; 95% CI, 1.26 to 3.88)

 

Takeaways/Caveats:

-68% of arrests witnessed, 58% received bystander CPR, median response time of 7.4-7.8 min

-Did not reach planned sample size 2/2 COVID pandemic

-No reporting of post-arrest care (e.g. TTM, PCI)

-Overall rates of survival and good neuro outcome on the higher side even with standard of care

-More/larger studies needed, but can consider DSED for refractory vfib, particularly if you are in a setting without more advanced circulatory support/resources

 

 

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IPV can occur once or over years by a current or former romantic partner.  Types of IPV include: Physical and/or Sexual violence, Stalking, and Psychological/Financial aggression (the use of verbal and non-verbal communication to harm mentally or emotionally and to exert control over another partner). 

IPV is more prevalent that Aortic Dissection and Pulmonary Embolism combined.   Think about how risky it is to NOT recognize IPV.

1:4 women and 1:10 men have been victims of IPV during their lifetime.

1:5 homicide victims are killed by an intimate partner.

Over 50% of female homicide victims are killed by a current or former intimate partner.  Patients who have been strangled are 4 times more likely to be killed within a year.

Your Spidey Sense should go off when:

1. Stories Change
2. History doesn’t match up with injuries
3. Injuries in areas that are concealed, multiple injuries of varying ages, defensive wounds
4. Major delays in seeking care
5. Non-specific complaints - headache, gastric issues
6. Multiple ED visits at odd hours
7. Refusing the use of an interpreter by partner (why we always use an official interpreter)

 

Once patient is identified as a victim:

1. Place victim in a safe, inaccessible by visitors, and hidden area
2. Treat all medical issues
3. Contact Social Work/SAFE/SANE examiner (some institutions will have IPV specific resources)
4. Contact police if patient is willing to report
5. Safe disposition
6. If unable to ensure a safe disposition, be very careful about documentation provided in discharge paperwork and language used

 

 

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Sugammadex works by chelating non-depolarizing neuromuscular blocking agents (NMBA) such as rocuronium and vecuronium to reverse the effects of paralysis.  Dosing per package insert varies based on time from administration of the NMBA, and side effects, although rare, include severe bradycardia, hypotension, and asystole. While sugammadex is routinely used by our anesthesia colleagues, it is rarely utilized in the emergency department (ED) or intensive care unit (ICU) setting. 

A recent single-center study assessed 11 patients with either a traumatic brain injury (TBI) or intracranial hemorrhage (ICH) who received sugammadex for neurologic assessment in the ED or ICU.  The median dose was 240mg and the median time since last NMBA administration was 101 minutes.

In 6/11 patients, the neurosurgical plan changed and it affirmed a poor prognosis in 3/11 patients. In the ICU patients, sugammadex was associated with reduction in unnecessary tests.

All patients had a GCS of 3T prior to administration and 67% responded to sugammadex with a median increase to 8T (P=0.0156).  MAP reductions were common with a median of -8 mmHg.

Bottom Line:  Sugammadex can assist in determining a neurosurgical or clinical prognosis plan in patients with TBI and ICH.  Larger studies are needed in this patient population and caution should be used inpatients who are already hypotensive or bradycardic.  A reasonable dose, especially when given >1h from intubation would be 200mg.  The team should be available at administration to note changes in GCS.

 

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This retrospective study compared plain radiographs to CT scan for the detection of pelvic fractures in patients over 65 years of age. The authors concluded “Pelvic radiographs have low sensitivity in detecting traumatic pelvic fractures. These radiographically occult fractures may be clinically significant as a cause of long-term pain and may require orthopedic consultation and possible surgical management.”

If you have a high clinical suspicion due to pain or inability to ambulate, CT may be warranted if the X-Ray is negative. 

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Subcutaneous Fluid Administration for Rehydration

• An old school technique (described in the 1800’s) that fell out of favor but still has applicability - primarily in pediatrics although it has been explored for use in geriatrics and mass casualty events (due to ease and speed of use)
• Most appropriate for stable but mildly to moderately dehydrated patients who need rehydration, are not tolerating PO, and in whom an PIV is difficult to establish (this should not replace an IO in a critically ill child)
• Either a small gauge angiocath or butterfly can be used for access
• Most common area to access in younger children is between the shoulder blades, although the lateral abdomen, thighs, or outer upper arms can be used as well; the site must have adequate subcutaneous tissue (can test by pinching between the fingers)
• Subcutaneous catheter placement is generally quite easy, however care should be taken with securing the catheter as there will be expected swelling at the area which can cause dislodgement or discomfort
• Mild erythema may also occur at the site of administration
• Injection of hyaluronidase (150 U) at the site being used increases the volume that can be administered as well as speed of absorption (hospitals may carry this product for treatment of severe PIV infiltration events)
• It is not necessary to have hyaluronidase to utilize subcutaneous fluid administration, but improves efficiency and efficacy
• Fluids administered should be isotonic and can be administered at 20 mL/kg over an hour – this can be repeated as necessary

 

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Airway Pressure Release Ventilation (APRV) is an "advanced" mode of mechanical ventilation that has long been considered a "rescue" mode of ventilation and has recently garnered much more attention during the COVID pandemic.  Given the long boarding times of critical care patients in the ED with widespread improvement in sight, I wanted to send out some great resources that have come out recently delineating the difference in thought process between APRV as a "rescue" mode and as a "primary" mode.

Rory Spiegel of EMNerd and former UMMC CCM fellow has recently given a great talk on APRV and its use as a rescue mode of ventilation. See also Phil Rola's recent paper listed on that webpage.

https://emcrit.org/emcrit/aprv-for-lung-rescue/

 

APRV as a primary mode of ventilation has been used in the STC for years and is often referred to in the literature according to the basic ventilatory philsophy called Time Controlled Adaptive Ventilation. I realize this may be heresy to some and perhaps a curiousity to others. I recommend you take some time to peruse the following resources:

1. Dr. Habashi has done a great deal of work in the basic and translation literature on APRV and TCAV. His recent review dispels many myths and concerns surrounding APRV

Myths and Misconceptions of Airway Pressure Release Ventilation: Getting Past the Noise and on to the Signal - https://www.frontiersin.org/articles/10.3389/fphys.2022.928562/full

2. The TCAV Network has great resources for those who want to do a deeper dive into this topic. 

https://www.tcavnetwork.org/

(Can also find their recommended protocols at the Multi Trauma Critical Care education website: https://stcmtcc.com/handouts/)

 

Attachments

• 2211021655_fphys-13-928562_(2).pdf (5,575 Kb)
• 2211021655_Standard_Settings_for_APRV_using_the_TCAV_Method.pdf (1,525 Kb)
• 2211021655_APRV_TCAV_Rescue_Strategy_Strategy_Guidelines_2020.pdf (1,614 Kb)

Traditional trauma teaching is to admit trauma patients with abdominal wall ecchymosis caused by seat belts (seat belt sign) for fear of missing a hollow viscus injury leading to peritonitis and sepsis.  

Over the past few years there have been studies pointing toward the safety of discharging blunt abdominal trauma patients with a negative CT even if they do have a seat belt sign.

In this most recent study, a negative CT was defined as 

1. No free fluid (free fluid was the leading indicator of occult hollow viscus injury)

2. No solid organ injury

3. No bowel wall irregular contours, thickening, hematoma or air

4. No abdominal wall soft tissue contusion

5. No mesenteric stranding or hematoma

6. No bowel dilatation

If the patient’s CT did not include any of these findings, there was a 0.01% chance of finding a delayed hollow viscus injury. The authors conclude it is safe to discharge patients meeting these criteria. 

If we include no rebound or guarding on physical exam along with a negative CT scan, it appears to be safe to discharge trauma patient’s with seat belt sign.

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Arterial line waveform interpretation and troubleshooting are essential skills for any physician caring for critically ill patients. Overdamping and underdamping of the arterial line waveform leads to inaccurate systolic and diastolic blood pressure readings which can lead to unidentified hypertension or hypotension. In addition to scrutiny of the arterial waveform pattern, the square-wave test is a tool to identify overdamped or underdamped arterial lines. 

Overdamped arterial waveforms will underestimate systolic blood pressure and overestimate diastolic blood pressure. Underdamping will have the opposite effect and overestimate systolic blood pressure and underestimate diastolic blood pressure. In both cases, the mean arterial pressure (MAP) often remains the same.  

The square-wave test is a rapid flush that is applied to the arterial line for approximately 1 second. This rapid high-pressure surge results in vibration and oscillation of the arterial catheter. These oscillations are then read by the pressure transducer and the number and amplitude of these oscillations can be measured. 0 or 1 oscillations is suggestive of overdamping. 3 or more oscillations is suggestive of an underdamped system. 

Major causes of an overdamped arterial line waveform include low infusion bag pressure, loose connectors, air bubbles in the tubing, blood clot in the circuit, or kinking of vascular catheter. An underdamped arterial line, however, is caused by overly stiff circuit tubing or a defective transducer.   

 

Scrutiny of the arterial waveform and utilization of the square-wave test can be helpful to both identify erroneous arterial line blood pressure readings as well as suggest likely corrective measures.  

 

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Attachments

• 2210242137_Arterial_line_overdamped_and_underdamped_examples.jpg (112 Kb)

This meta-analyisis looked at whether obesity was a protective factor for penetrating trauma (the armour phenomenon). The authors concluded that insteaed of being protective, obesity added to morbidity and mortality.

"Obese patients that sustained stab injuries underwent more nontherapeutic operations. Obese patients that sustained gunshot injuries had longer intensive care and total hospital length of stay. Obese patients suffered more respiratory complications and were at an increased risk of death during their admission."

Further evidence that obesity is a major health concern in both medical and trauma pateints. 

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Developmental dysplasia of the hip (DDH) 

 

• A spectrum of conditions related to hip development in infants & young children
• Results from abnormal development of the acetabulum and proximal femur
• Results in mechanical instability of the hip joint 
• Left hip (3:1) vs Right
• Female sex (5:1)
• Breech presentation (20%)
• Family history of DDH
• Infants and young children with untreated hip dislocation rarely have pain or other limitations.
• Most affected children begin to walk and reach developmental milestones at the appropriate time.
• In cultures where tight swaddling with the lower limbs in extension is common, significantly higher rates of DDH have been reported.
• In South Australia 79% of those with DDH were tightly swaddled
• In Japan, when traditional swaddling was used, the incidence of DDH was 5%.
• A public campaign to switch to wrapping techniques encouraging hip flexion and abduction led to DDH rates falling to less than 0.4%.
• https://res.cloudinary.com/dbwozcf0d/images/f_auto,q_auto/v1589948650/10624649_794826423982877_5167788043433556178_n/10624649_794826423982877_5167788043433556178_n.jpg

 

Once the diagnosis of intussusception is made, there are often delays in 1) getting the patient to a center where reduction can be performed and 2) getting the staff available to perform an air enema, especially during evenings and nights. Previous studies have shown worse outcomes when there is longer than a 24 hour delay in reduction. This was a retrospective single center study looking at 175 cases of intussusception and evaluating the time between the radiology final read of intussusception and the timing of reduction and if enema based reduction was successful. In this group of patients, there was no statistically significant difference in reduction efficacy, requirement for surgical reduction or complication rate (bowel resection or perforation) in the patients studied which included delay intervals up to 8 hours. Successful first attempt reductions ranged from 72-81% in each study group (1hr, 1-3hr, 3-6hr and 6+ hr). The caveat to this study is that there were only 11 patients included in the 6-8 hour group. This study also did not take into account the timing from symptom onset to reduction time. Bottom line: More evidence is needed, but this small study provides evidence that up to 8 hours from radiology diagnosis of intussusception to the 1st reduction attempt was not less efficient compared to those with an attempt in under 1 hour.

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Emergency physicians are familiar with posterior reversible [leuko]encephalopathy syndrome as an entity associated with untreated hypertension. It also happens to be a well-documented entity amongst solid organ transplant patients.  

While the exact pathophysiology remains unclear, PRES is characterized by posterior subcortical vasogenic edema due to blood-brain barrier disruption, usually in the setting of elevated blood pressure with loss of cerebral autoregulation and/or endothelial dysfunction.

The immunosuppressants used in this population, namely calcineurin inhibitors (CNI) such as tacrolimus and cyclosporine, are thought to contribute most to this endothelial dysfunction and development of PRES in transplant patients, although high-dose corticosteroids, ischemia-reperfusion injury during surgery, and antibiotics have also been implicated. 

Presentation of PRES post-transplant:

Clinical symptoms:

• Seizures (75-85%)
• AMS - confusion/somnolence (30-40%)
• Headache (25-50%)
• Vision disturbance (20-40%)

Time course:

• Within weeks to a year posttransplant, rarely after a year
• Rapid onset once it starts, can develop over hours to days

Diagnostics:

• Labs nonspecific, although supratherapeutic CNI levels are often associated with:
  • Acute renal injury
  • Hyperchloremic metabolic acidosis
  • Hyperkalemia
  • Hypomagnesemia
  • Hypercalciuria
• Thoughts on checking FK506 (tacrolimus) levels
  • For transplant patients, usually advise only checking troughs (~12 hrs after last dose)
  • A low random level may rule out CNI toxicity but not PRES
  • A high random level isn't really helpful
• MRI is diagnostic modality of choice >> subcortical edema, usually bilateral, symmetric, in parieto-occipital regions

Management:

1. Stabilization via supportive care – seizure, cerebral edema, BP management as applicable, etc.
2. Withdrawal/holding of offending agent – will require consultation with transplant physician and pharmacist usually by inpatient team
   • Mixed data re: use of CYP-inducers to lower CNI levels in CNI toxicity

Bottom Line: 

Patients with a history of solid organ transplant are at risk for PRES. While ED stabilization of these patients remains the same, recognition of PRES as a potential etiology for a transplant patient's presentation is crucial to proceed with important testing and necessary changes to their immunosuppressive regimen. 

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