Check for Elevated ICP in the Post-ROSC Patient
This study looked at older patients admitted to the hospital with a diagnosis of one of the following: RSV infection, UTI, influenza, fracture. Those patients with RSV had longer stays, higher mortality, higher ICU length of stay and interestingly more cardiovascular complications up to one year after hospitalization. Further evidence we should be testing for RSV in our ill older patients and encouraging vaccination.
Premature infants in the NICU are often given caffeine to help to prevent apneic episodes and this has been proven safe. This study aims to determine if caffeine will help infants < 8 weeks with bronchiolitis, even if there is no concern for apnea. The current recommended treatment for bronchiolitis is supportive care.
2 French Hospitals with the same protocols and resources for bronchiolitis participated. All infants admitted to each hospital with a diagnosis of bronchiolitis were included. Infants who presented to Hospital A received caffeine and infants who presented to hospital B did not. The remainder of their care was similar. The caffeine was given as a bolus dose followed by a daily maintenance dose until there was clinical improvement. The dose was the standard dose used in premature infants with apnea as recommended by the French National Authority for Health. There were 26 patients at the study hospital that did not receive caffeine for an unknown reason. 65 patients received caffeine.
The study had several areas showing statistical significance:
In the subgroup of RSV + patients, those who did NOT receive caffeine had a higher incidence of requiring ventilatory support.
The use of high flow nasal cannula was HIGHER in the group with NO caffeine.
The use of CPAP was HIGHER in the caffeine group BUT the duration of CPAP use was shorter compared to the NO caffeine group.
The need for nutritional support was higher in the NO caffeine group.
There were a few cases of temporary tachycardia and irritability in the caffeine group which resolved several hours after the medication was given.
A larger study is needed, but in this small group, there may be an indication for caffeine outside of the NICU for infants < 8 weeks.
Delirium is common among critically ill patients. Some of the common Acetylcholinesterase inhibitors (AChEI), rivastigmine, donepezil, have been used to prevent delirium in ICU patients. However, their efficacy was just recently re-examined in a meta-analysis of only Randomized Control Trials.
Ten studies and 731 patients were included- 365 in the treatment (AChEI) group and 366 in the control group.
AChEI was associated with lower occurrence of delirium (RR 0.68, 95% CI 0.47-0.98, p=0.039. However, there was no significant difference in the delirium duration (mean difference -0.16 day, 95% CI -0.95 to 0.62 day, p=0.23). There was no difference in delirium severity nor length of hospital stay.
Among the medication, interestingly, rivastigmine 4.5 mg/day significantly reduced delirium occurrence (RR = 0.61 [0.39– 0.97]) and severity (SMD = –0.33 [–0.58 to –0.08]), as well as length of hospital stay (MD = –1.29 [–1.87 to –0.72]).
Discussion:
This meta-analysis was well-conducted.
The cholinergic dysregulation—especially elevated acetylcholinesterase activity—can lead to the imbalance between attention and cognition, contributing to delirium in ICU patients. Thus, the use of AChEI and reduction of occurrence of delirium proves that acetylcholine deficiency may be associated with delirium among ICU patients.
Subgroup analysis showed that prophylactic use of AChEI was associated with significant reduction of delirium duration. Thus, further studies are needed to define which populations will benefit from AChEI.
Conclusion:
AChEIs are effective in reducing occurrence of delirium, but they did not affect delirium duration, severity or hospital LOS.
At this point, we've likely all encountered a patient who is on aspirin as a preventative for a history of pre-eclampsia or high risk pregnancy, but what about for low risk patients who have not yet had any children?
This meta-analysis came out in August of this year looking at RCTs that examined giving low dose aspirin to low-risk (no pre-eclampsia, gestational DM/HTN, autoimmune or renal disease), nulliparous individuals during pregnancy and found that while not all doses of aspirin at all ages were helpful, a planned subgroup analysis showed that giving 100mg of aspirin daily starting before 16 weeks cut the odds of preterm birth before 37 weeks in about half (RR 0.45).
That's not to say that we should all be starting aspirin for our patients in the emergency department just yet - but this might be why you're seeing aspirin pop up on more of our pregnant patients' medication list (or why your OB might be recommending it to you or your family/friends).
These authors used information available from both the medical record as well as from a survey instrument given in the emergency department to created this fall risk score. A score over 6 had a 63% sensitivity and 75% specificity of predicting future falls.
Use of Muscle Relaxants in the Elderly
A recent pearl discussed the risks of skeletal muscle relaxants (SMR) in the elderly population.
Risks included sedation, confusion, disorientation, orthostatic hypotension and increased risk for falls and fractures.
The Beers Criteria is a list of medications that older adults should generally avoid due to potential adverse effects.
Two commonly used muscle relaxants, Baclofen and Tizanidine (Zanaflex) are not included in the Beers criterion.
A study published last month investigated the safety profile of these medicines as compared to cyclobenzaprine (Flexeril).
Retrospective cohort study of Kaiser Permanente Southern California patients aged 65 to 99 years between 2008 and 2018.
From a population of approximately 88,000 participants (mean age 71.4 years; 59.8% women), approximately 118,000 study medication episodes were identified: 54.8% participants were dispensed baclofen, 6.3% tizanidine, and 38.9% cyclobenzaprine
Outcomes included injury-related hospitalizations, emergency department visits, and urgent care visits documented in EMR and identified through diagnostic codes for fractures, falls leading to fractures, brain injuries, and dislocation injuries
Compared with cyclobenzaprine, Baclofen demonstrated a 69% greater risk (adjusted Hazard Ratio 1.69, [95% CI 1.51-1.88]) and tizanidine carried a 34% greater risk (adjusted Hazard Ratio 1.34, [95% CI 1.11-1.62]) for composite injury outcomes.
Conclusion: Older adult patients prescribed baclofen or tizanidine have an increased risk of injury when compared with Flexeril (currently included on the Beers Criteria)
As we enter cold and flu season, sinus issues become commonplace in the ED. What do we need to know about pediatric sinusitis?
First, it is important to know when pneumatization of the sinuses occur (so we don't look for symptoms where they can't be present). Completion of their development does not occur until around age 21 years.
Sinusitis should be a clinical diagnosis and does not require imaging unless there is concern for abscess development, cellulitis or other complications, or in cases where symptoms are not improving despite treatment.
In most otherwise healthy children, acute sinusitis is typically viral in nature, regardless of the color of nasal discharge, and can be managed with symptomatic care, including saline sprays, humidifiers, warm compresses and monitoring.
There are strict criteria for otherwise healthy children regarding when to initiate antibiotics including:
The antibiotic of choice is high-dose amoxicillin with or without clavulanic acid (cefpodoxime or cefdinir can be considered in penicillin allergic patients)
Antibiotic stewardship is critical in these patients, as unnecessary antibiotics can result in resistance or undesired side effects. There should be a clear conversation about return precautions with parents including education about the importance of symptomatic management over antibiotics in the first 10 days.
It is estimated that between 2.6% and 3.4% of patients undergoing rapid sequence intubation (RSI) experience awareness with paralysis, with the highest risk observed in patients receiving rocuronium. Several studies have now demonstrated prolonged time to sedation following RSI with long-acting paralytics, including a 2024 single-centered retrospective chart review by Dukes et al., which found that fewer than half of patients in the ICU receiving rocuronium for RSI were administered sedation within 15 minutes of intubation. The following study by Cappuccilli et al. sought to compare differences in sedation practices between the ED and ICUs at the same institution, hypothesizing that patients undergoing RSI in the ED would experience similar delays in sedation to those in the ICU.
In a retrospective observational study comparing patients both on and not on antithromotics (DOAC/warfarin or anti platelets) who presented with a GI bleed these authors found:
“Patients with anticoagulant therapy more often present with a lower source of GI bleeding than both those on antiplatelet medications and those with no antithrombotics. Overall patients on anticoagulants are also less likely to present with hematemesis, even with a later confirmed upper GI bleeding. Furthermore, results indicate that the need for endoscopic interventions and transfusions are dependent on initial presenting symptoms but not affected by antithrombotic therapy at admission.”
Q: Can you use high flow nasal cannula (HFNC) to manage acute hypercapnic respiratory failure?
A: It probably depends.
Background: While we now frequently utilize HFNC as an initial therapy for most acute hypoxic respiratory failure, its appropriateness in managing acute respiratory failure with hypercarbia has historically been opposed. With more recent data indicating that HFNC may be as good as noninvasive ventilation (NIV) for management of hypercapnia as well, this seemed like a good time to point out a few things:
The RENOVATE trial was a larger multicenter randomized noninferiority trial looking at HFNC vs NIV in all-comer acute respiratory failure, summarizing that HFNC was noninferior in the primary composite outcome of death + intubation at 7 days.
BUT this conclusion is not clearly supported in the smaller COPD (or acute cardiogenic pulmonary edema) subgroup:
What does seem to be clear across studies that HFNC has the capacity to clear some CO2 and is by and large better tolerated than facemask NIV.
Bottom Line: For mild-moderate acute COPD exacerbations with patient intolerance or exclusion criteria for NIV therapy, trialing HFNC is a reasonable option. For patients with severe acute or acute on chronic hypercapnia, as indicated by a [pseudo-arbitrary] pH < 7.25 and PaCO2 >70-80, noninvasive ventilation should be your go-to… or be ready to promptly intubate if/when the high flow fails.
A recent systematic review compared the timing and diagnostic accuracy of manual pulse check versus point-of-care ultrasound (POCUS) pulse checks (this means placing an ultrasound probe on the carotid or femoral artery to evaluate for a doppler pulse).
The review included seven studies encompassing a total of 469 patients.
Six of the studies assessed the duration of pulse checks, revealing a mean time difference of –1.39 seconds (95% CI: –2.20 to –0.57) in favor of ultrasound.
Three of the studies reported the sensitivity and specificity of POCUS pulse checks, yielding pooled estimates of 99% sensitivity (95% CI: 87%–100%) and 96% specificity (95% CI: 85%–99%). In contrast, two studies evaluated manual pulse checks, with pooled sensitivity of 62% (95% CI: 22%–91%) and specificity of 91% (95% CI: 88%–93%).
As with many systematic reviews, the studies included demonstrated high heterogeneity and generally low methodological quality, indicating that further investigation may still be needed.
This paper reminds us older patients have higher mortality and worse outcomes overall if their injury includes a head injury. Any mechanism that results in head injury, including fall from standing, has a higher potential for death, disability, and long term cognitive decline in older patients. Triaging these patients to trauma centers can lead to better outcomes. The difficulty is knowing which patients to send to trauma centers vs. emergency departments. The authors write:
"clinicians should consider transporting to a trauma center in geriatric patients with head trauma, if feasible. However, given the frequency with which head injury occurs, transportation to a trauma center for all patients with head trauma is likely to overwhelm EMS systems and hospitals. Unfortunately, the existing literature does not delineate the subset of patients whose condition will benefit from this evaluation . Given these considerations, we recommend EMS clinicians consider abnormal mental status, presence of anti-coagulation, and loss of consciousness as considerations to transport to a trauma center in cases where the need for trauma center evaluation is not clear.”
Reenforcing the recent pearl on geriatric trauma patient care, here is the National Association EMS Physicians statement on prehospital care.
"EMS clinicians should use age-adjusted, physiologic criteria to guide decisions to transport geriatric trauma patients to the most appropriate level of trauma center available in the community.
Geriatric trauma patients should be promptly evaluated for pain and should receive analgesic interventions in a timely manner. Analgesic medications should be dosed following weight-based guidance and should be administered with consideration of potential drug interactions and age-related changes in drug metabolism and side effects.
EMS clinicians should consult advance care planning documents, e.g., Physician Orders for Life-Sustaining Treatment (POLST), when available, to guide care in emergency scenarios, including management of traumatic injuries.
While older patients are at higher risk for spinal injuries, including lumbar and cervical spine fractures, traditional spinal motion restriction practices may not be suitable for older patients due to age-related anatomic changes in spinal alignment and increased risk for cutaneous pressure-related injuries. EMS clinicians should exercise judgment to determine when and how to best achieve spinal motion restriction if spinal injury is suspected in geriatric trauma patients."
In the pediatric ED, intranasal midazolam is a common choice among providers for procedural sedation. However, with widely varying recommendations, the ideal dose remains a topic of debate.
A recent randomized clinical trial published in JAMA Pediatrics involving 101 children, ages 6 months to 7 years, sought to determine the best dose of intranasal (IN) midazolam for sedation during laceration repair. Researchers compared four different doses: 0.2, 0.3, 0.4, and 0.5 mg/kg.
The primary outcome was achieving adequate sedation for at least 95% of the procedure. Secondary outcomes included the level of sedation, how quickly it took effect, recovery time, satisfaction of clinicians and caregivers, and any negative side effects.
What did they find?
The lower doses (0.2 and 0.3 mg/kg) were found to be less effective and were removed from the study early.
The two higher doses (0.4 and 0.5 mg/kg) both provided similar, adequate sedation for about two-thirds of the children.
Sedation took effect quickly, within a few minutes, and children recovered fast.
Adverse events were rare and not serious.
Satisfaction among both clinicians and caregivers was high across the board.
Bottom line: Consider reaching for higher doses of intranasal midazolam (0.4 to 0.5 mg/kg) for pediatric patients requiring procedural sedation.
This retrospective study looking at a readmission database for patients greater than 65 years categorized 10,000 patients into non-frail, pre-frail and frail based on the five-factor modified frailty index. They found no difference in recurrent diverticulitis among the groups but did find:
“frailty was a predictor of mortality on index hospitalization (adjusted odds ratio, 1.99; p < 0.001) and readmissions (adjusted odds ratio, 3.05; p < 0.001)…frail patients are at increased risk of mortality once they develop diverticulitis. Optimal management for frail patients with diverticulitis must be defined to improve outcomes.”
Once again, assessing your patient's frailty can help you predict outcomes and have meaningful discussions with patients and their families.
Settings: multinational, randomized, double- blind, placebo-controlled clinical trial conducted in 17 centers in Italy, Russia, and Kazakhstan
Participants: A total of 307 ICU patients with sepsis or septic shock. Patients who were likely to die (APACHE II > 65 points) were excluded.
Treatment group: 80 mg bolus of omeprazole at randomization, at 12 hours and infusion of 12 mg/hour for 72 hours. Total dose of 1024 mg.
Outcome measurement: primary outcome of the study was organ dysfunction measured as the mean daily SOFA score during the first 10 days. Secondary outcomes were antibiotics-free days at 28 days; all-cause mortality at 28 days
Study Results:
Discussion:
Conclusion:
In sepsis patients, Esomeprazole did not re- duce organ dysfunction, despite demonstrating in vivo immunomodulatory effects
Carbon Monoxide Poisoning (COP) is a major toxicologic pathology and a common case in the Emergency Department and pre-hospital setting. History is a key component in assessment with the standard diagnostic test being blood gas analysis of Carboxyhemoglobin (COHb).
Standard pulse oximeter devices are not capable of differentiating oxyhemoglobin from carboxyhemoglobin, leading to the classic pearl that pulse ox may be falsely reassuring in COP.
In recent years, devices capable of differentiating oxyhemoglobin from COHb have been developed and are fielded in many hospitals and EMS agencies.
This meta-analysis reviews diagnostic accuracy of pulse CO-oximetry (spCO) devices in comparison to a reference standard COHb blood test. Six studies (1734 patients) were included.
This analysis found that spCO testing has a low sensitivity and high specificity.
Pooled sensitivity 0.65 (95% CI 0.44–0.81)
Pooled specificity 0.93 (95% CI 0.83–0.98)
Pooled LR+ 9.4 (95% CI 4.4 to 20.1)
Pooled LR- 0.38 (95% CI 0.24 to 0.62)
The authors conclude that the low sensitivity precludes use of spCO as an effective screening tool for COP or substitute for COHb. Conversely, we can recognize the utility of the high specificity in identifying patients who do have clinically significant toxicity. Indeed, the authors discuss potential applications for triage and transport to a hyperbaric oxygen chamber for those who are found to have elevated readings.
Technology advancement and refinement will be interesting to follow. In the meantime, don’t skip the COHb lab just because spCO measurement is reassuring.
This review article reminds us that abdominal hypertension and compartment syndrome need to remain on our differential diagnosis for critically ill and injured patients. Pressure is measured with an intra-bladder catheter. Normal pressure is 5-7 mm HG. Sustained over 12 mm Hg is hypertension and sustained over 20 mm Hg is compartment syndrome.
Use of Muscle Relaxants in the Elderly
A 2023 Cochrane Database review found moderate-certainty evidence that muscle relaxants may increase the risk of adverse events.
Primary adverse events are due to CNS depressant effects (dizziness, sedation) and anticholinergic effects.
Geriatric patients already have baseline unsteady gait, decreased coordination and cognitive changes.
A 2015 study showed that geriatric patients who took muscle relaxants were 2.25 times more likely to visit the ED for a fall or fracture and 1.5 times more likely to be hospitalized for a fall or fracture than patients who did not take these medications.
Risk is greatest in patients >65 years of age. This population was 1.32 times more likely to have an injury compared to patients who did not take skeletal muscle relaxants.
