Category: Critical Care
Posted: 9/7/2021 by Mike Winters, MBA, MD
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Management of Intermediate-High Risk PE Patients
Weinstein T, et al. Advanced management of intermediate-high risk pulmonary embolism. Crit Care. 2021; 25:311.
Category: Pediatrics
Keywords: sickle cell, HgSS, fever, sepsis (PubMed Search)
Posted: 9/3/2021 by Natasha Smith, MD
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Miller, Scott and Kusum Viswanathan. "Sickle Cell Anemia with Fever." Atlas of Pediatric Emergency Medicine, 3rd Edition, edited by Binita Shah, McGraw-Hill, 2019, 510-511.
Category: Critical Care
Posted: 8/31/2021 by Lucas Sjeklocha, MD
Click here to contact Lucas Sjeklocha, MD
Background: Interest in moving to balanced fluid administration has grown after publication of the SPLIT trial and SALT-ED/SMART trials, which showed respectively evidence of benefit to balanced crystalloid over normal saline on mortality and major adverse kidney events at 30 days.
Population/Intervention: The BaSICs trial is an RCT in 75 ICUs in Brazil, testing P-Lyte versus NS (with each arm getting two different infusion rates that were analyzed as a separate trial) for volume administration per protocol.
--10,520 ICU patients requiring fluid expansion, expected ICU stay >1 day, and 1 additional risk factor for AKI (age>65, hypotension, sepsis, MV, NIV, oliguria, elevated creatinine, cirrhosis, or acute liver failure).
--Exclusions: severe dysnatremia, expected RRT within 6 hours, expected death.
--Average age was 61, with a SOFA score of 4, and 48% on were elective surgical admissions.
Outcome:
--No difference in 90 days mortality (P-Lyte 26.4% v NS 27.2, aHR p=0.47), AKI or RRT out to 7-days, or in duration of MV, ICU LOS or hospital LOS
--Median study fluid by day 3 was 2.9L in each group
--Higher neurological SOFA score observed in P-Lyte group
--Higher mortality seen with P-Lyte in TBI subgroup (P-Lyte 31.3% vs NS 21.1%, p=0.02)
Discussion:
--Adds contrasting negative data to previous large positive RCTs showing benefit of balanaced fluids
--Expect further reanalysis/metanalysis of BSS versus NS trials
--Signal for harm in TBI pts with P-Lyte correlates with SMART point estimates that were not significant
--Compared to SMART trial population BaSICs had: 2x higher mortality, more planned surgery, received about 1L more study fluid in the first 3ds
Takeaway:
--Balanced crystalloid versus normal saline debate will continue considering this large negative trial
--Signal for possible harm in TBI population with balanced crystalloids compared to normal saline
References:
Category: Neurology
Keywords: Sport concussion, brain injury (PubMed Search)
Posted: 8/28/2021 by Brian Corwell, MD
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Athletes with a history of concussion had an average cerebral blood flow of 40 mL per minute, per 100 grams of brain tissue.
Athletes without a history of concussion had an average cerebral blood flow of 53 mL per minute, per 100g of brain tissue.
In the weeks following concussion, those athletes with a prior history of concussion had microstructural changes in the corpus callosum.
Effects were seen in the absence of differences in SCAT domains or time to return to sport.
Acute and Chronic Effects of Multiple Concussions on Midline Brain Structures. Churchill et al. Neurology Aug 2021.
Category: Critical Care
Keywords: SOFA, sepsis, oxygen saturation (PubMed Search)
Posted: 8/25/2021 by Quincy Tran, MD, PhD
(Updated: 12/9/2024)
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Background: SOFA score has been used as a predictor for poor outcomes in patients with sepsis. However, the original SOFA score utilizes PaO2/FiO2 ratio to calculate the SOFA’s respiratory component. When there are no ABG, thus no PaO2, we have to convert patients’ spO2 to PaO2, and the amount of oxygen support to FiO2 (for example, 2 liters of oxygen via nasal cannula = 0.27). This is cumbersome.
Objective: This study assessed whether spO2 can be used instead of PaO2/FiO2 ratio for SOFA’s respiratory score.
Settings: 8 hospitals across Sweden and Canada
Patients: Adults with sepsis. 19396 patients were included for the derivation group while there were 10586 patients for the validation cohort.
Study Results:
Discussion:
Valik JK, Mellhammar L, Sundén-Cullberg J, Ward L, Unge C, Dalianis H, Henriksson A, Strålin K, Linder A, Nauclér P. Peripheral Oxygen Saturation Facilitates Assessment of Respiratory Dysfunction in the Sequential Organ Failure Assessment Score With Implications for the Sepsis-3 Criteria. Crit Care Med. 2021 Aug 18. doi: 10.1097/CCM.0000000000005318. Epub ahead of print. PMID: 34406170.
Category: Pediatrics
Keywords: hyperthermia, pediatrics, car (PubMed Search)
Posted: 8/20/2021 by Jenny Guyther, MD
(Updated: 12/9/2024)
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- A higher metabolic rate, reduced capacity for sweating, greater thermolability, and a larger body surface-to-volume ratio make infants and young children more susceptible to hyperthermia.
- Temperatures can rise rapidly within enclosed vehicles, reaching maximum temperatures within 5 minutes. In an open area with an ambient temp of 98 F (36.8 C), interior temperatures reach 124-152 F (51 to 67 C) within 15 minutes of closing the car doors.
- Texas leads the country in the numbers of pediatric heatstroke fatalities due to unattended children left in cars, followed by Florida and California.
- Most heatstroke victims (78.2%) were unknowingly left in vehicles by their caregivers.
- Most organizations interested in child safety issues recommend placing a phone, briefcase, or handbag in the back seat when traveling with a child as one way to prevent heatstroke fatalities.
Category: Toxicology
Keywords: ICU requirement score, physiologic score system (PubMed Search)
Posted: 8/19/2021 by Hong Kim, MD
(Updated: 8/20/2021)
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There are several clinical scoring systems (SAPS II, SAPS III, SOFA, etc.) to assess the severity and/or risk of mortality in critically ill patients. However, the routinely used physiologic scoring systems are not always suitable for poisoned patient.
ICU requirement score (IRS) has been recently developed by investigators from Europe and a validation study (retrospective cohort) has been performed.
ICU requirement score (IRS) components (see inserted table)
Retrospective cohort
Results
N=1503
Area under the curve for IRS ROC: 0.736 (95% CI: 0.702-0.770)
IRS <6
Conclusion
Category: Critical Care
Keywords: IVF, intravenous fluids, resuscitation, infusion rates (PubMed Search)
Posted: 8/18/2021 by Kami Windsor, MD
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Background:
There are also no clear guidelines regarding how fast fluid boluses should be administered, and there has been debate about whether different infusion rates could lead to different outcomes in patients receiving intravenous fluid (IVF) boluses (i.e. fast infusions may cause more third spacing due to the rapidity of the expansion of the intravascular space compared to fluid administered more slowly). A recent study compared IVF infusion rates in ICU patients.
-- Unblinded, randomized
-- 10,520 patients clinically requiring a fluid challenge, from 75 ICUs in Brazil
-- Infusion rate 333 mL/hr vs 999 mL/hr
* (Trial also compared plasmalyte vs 0.9% saline, analyzed in separate study)
-- Some notable exclusion criteria: severe hypo/hypernatremia, AKI or expected to need RRT 6 hrs after admission
--Other caveats:
* Faster infusion rates allowed at physician discretion in patients with active bleeding or severe hypotension (SBP < 80 or MAP < 50 mmHg); patient was returned to assigned rate after condition resolved
* Almost 1/2 the patients received at least 1L of IVF in 24 hours prior to enrollment
-- Results: No sig difference in 90-day survival, use of RRT, AKI, mechanical ventilator free days, ICU/hospital mortality/LOS
Bottom Line: There is not yet compelling evidence that there are differences in patient outcomes in patients receiving fluid boluses given at 333 cc/hr vs. 999 cc/hr.
1. Zampieri FG, Machado FR, Biondi RS, et al. Effect of slower vs faster intravenous fluid bolus rates on mortality in critically ill patients: the basics randomized clinical trial. JAMA. Published online August 10, 2021.doi:10.1001/jama.2021.11444
2. Zampieri FG, Machado FR, Biondi RS, et al. Effect of intravenous fluid treatment with a balanced solution vs 0. 9% saline solution on mortality in critically ill patients: the basics randomized clinical trial. JAMA. Published online August 10, 2021.
Category: Orthopedics
Keywords: pressure, exercise, lower extremity (PubMed Search)
Posted: 8/14/2021 by Brian Corwell, MD
(Updated: 12/9/2024)
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Chronic Exertional Compartment Syndrome (CECS)
Similar pathology to acute compartment syndrome except symptoms are related to activity (frequently running) and abate with rest.
95% involve lower extremity
Inappropriately elevated tissue pressure in one or more lower leg compartments associated with exercise
Anterior compartment most frequently involved
As tissue pressure increases, local perfusion is decreased. This leads to symptoms of pain, pressure, cramping and paresthesias.
Also commonly associated with team sports such as soccer, lacrosse and field hockey.
More likely in competitive athletes than recreational.
Patient will be symptom free at time of ED evaluation
Make diagnosis of CECS with history
Diagnosis with compartment pressure measurements done in office with treadmill exercise.
Non operatively, gait retraining programs have been shown to help symptoms. Appropriate if symptoms are mild.
Surgical treatment involves a minimally invasive fasciotomy
Post surgery success rates are between 63-100% with recurrence rates up to 20%
Category: Critical Care
Keywords: cardiac arrest, IHCA, resuscitation, epinephrine, pediatrics (PubMed Search)
Posted: 8/11/2021 by Kami Windsor, MD
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Approximately 15,000 children experience an in hospital cardiac arrest (IHCA) with little improvement in outcomes over the last two decades. During that time, epinephrine has been the constant basis for resuscitation of these patients. Current recommendations by the AHA recommend bolus dosing of epinephrine every 3-5 minutes in a pediatric cardiac arrest. Animal studies suggest that more frequent dosing of epinephrine may be beneficial.
This was a retrospective study of 125 pediatric IHCAs with 33 receiving “frequent epinephrine” interval (≤2 minutes). Pediatric CPC score 1-2 or no change from baseline was used as primary outcome to reflect favorable neurologic outcome, with frequent dosing associated with better outcome (aOR 2.56, 95%CI 1.07 to 6.14). Change in diastolic blood pressure was greater after the second dose of epinephrine among patients who received frequent epinephrine (median [IQR] 6.3 [4.1, 16.9] vs. 0.13 [-2.3, 1.9] mmHg, p=0.034).
This study is subject to all sorts of confounding and should be studied more rigorously, but suggests that more frequent dosing for pediatric IHCA may be of benefit.
Kienzle MF, Morgan RW, Faerber JA, et al. The Effect of Epinephrine Dosing Intervals on Outcomes from Pediatric In-Hospital Cardiac Arrest. Am J Respir Crit Care Med. 2021. doi: 10.1164/rccm.202012-4437OC.
Category: Pediatrics
Keywords: RSV, bronchiolitis (PubMed Search)
Posted: 8/6/2021 by Rachel Wiltjer, DO
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CDC. Increased Interseasonal Respiratory Syncytial Virus (RSV) Activity in Parts of the Southern United States. Health Alert Network. Published online June 10, 2021.
Ralston, S., Lieberthal, A., et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. Nov 2014. 134(5) e1474-1502.
Category: Critical Care
Keywords: Modified Clamshell thoracotomy, resuscitative thoracotomy, randomized control trial (PubMed Search)
Posted: 8/3/2021 by Kim Boswell, MD
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Resuscitative thoracotomy is a dramatic and heroic procedure used in the emergency department in an attempt to resuscitate a patient in arrest due to trauma. There are a few techniques commonly used, but due to the extreme nature of the procedure no prior randomized controlled trials (RCTs) have been done.
The modified clamshell thoracotomy (MCT) is a technique in which the standard left anterolateral thoracotomy (LAT) is extended across the sternum, but does not involve surgical opening of the right chest. The MCT allows for increased visualization of the mediastinum and thoracic cavity structures.
Sixteen Emergency trained physicians (approximately half attending and half senior residents) from a level 1 trauma center underwent didactic and skill based training on both the MCT and LAT techniques using fresh, human cadavers. Following training they were randomized based on order of intervention, performing both techniques.
Their thoracotomies were assessed by a board certified surgeon and “success” was determined based on the complete delivery of the heart and cross clamping of the descending aorta.
Primary outcome: time to successful completion of procedure
Secondary outcomes: successful delivery of the heart from the pericardial sac (as well as time to delivery), cross clamping of the aorta (and time to clamping), procedural completion and number of iatrogenic injuries.
Overall, there was no statistical difference in primary outcome or successful completion between the MCT compared to the LAT (67% vs. 40%). However, 100% of the LAT resulted in some form of iatrogenic injury (rib fractures, lacerations of the diaphragm,/esophagus/heart/lung) compared to 67% of the MCT technique. There was no associated difference in success when previous experience (attending vs. senior resident) were compared. Lastly, MCT was the favored technique of the majority of the study subjects.
Prospective Randomized Trial of Standard Left Anterolateral Thoracotomy Versus Modified Bilateral Clamshell Thoracotomy Performed by Emergency Physicians. Ann Emerg Med. 2021 Mar;77(3):317-326 doi: 10.1016/j.annemergmed.2020.05.042nnemergmed.2020.05.042Prospective Randomized Trial of Standard Left Anterolateral Thoracotomy Versus Modified BiProspective Randomized Trial of Standard Left Anterolateral Thoracotomy Versus Modified Bilateral Clamshell Thoracotomy Performed by Emergency Physicians. Ann Emerg Med. 2021 Mar;77(3):317-326 doi: 10.1016/j.annemergmed.2020.05.042lateral Clamshell Thoracotomy Performed by Emergency Physicians. Ann Emerg Med. 2021 Mar;77(3):317-326 doi: 10.1016/j.annemergmed.2020.05.042
Category: Pediatrics
Posted: 7/31/2021 by Rose Chasm, MD
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Munden M, Williams J, Zhang W, Crowe J, Munden R, Cisek L. Intermittent Testicular Torsion in the Pediatric Patient: Sonographic Indicators of a Difficult Diagnosis. Am J Roent. 2013;201:912-918.
Pogoreli? Z, Mrkli? I, Juri? I. Do not forget to include testicular torsion in differential diagnosis of lower acute abdominal pain in young males. J Pediatr Urol. 2013;9:1161–1165.
Janetschek G, Schreckenberg F, Mikuz G, Merberger M. Experimental testicular torsion: effect on endocrine and exocrine function and contralateral testicular histology. Urol Res 1998; 16:43–47.
Kamaledeen S, Surana R. Intermittent testicular pain: fix the testes. BJU Int 2003; 91:406–408.
Sung EK, Setty BN, Castro-Aragon I. Sonography of the pediatric scrotum: emphasis on the Ts—torsion, trauma, and tumors. AJR 2012; 198:996–1003.
Category: Critical Care
Keywords: COVID-19, Antiviral, Hydroxychloroquine (PubMed Search)
Posted: 7/27/2021 by Mark Sutherland, MD
(Updated: 12/9/2024)
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The much anticipated REMAP-CAP trial was epublished ahead of print July 12th in Intensive Care Medicine. It was an RCT investigating four antiviral strategies in critically ill adults with COVID-19: lopinavir-ritonavir, hydroxychloroquine, a combination of the two, and no antiviral therapy (control group).
Despite the hype around protease inhibitors, hydroxychloroquine, and other unproven therapies in COVID (lookin at you next, Ivermectin...), all three strategies had WORSE outcomes than placebo. They all decreased organ-support-free days (all reaching statistical significance), which was the primary outcome. They also all led to longer ICU time, longer time to hospital discharge, and reduced 90 day survival. Not only does this study show no benefit, it shows fairly convincing signs of harm to these therapies.
Bottom Line: Protease inhibitors (e.g. lopinavir-ritonavir) and hydroxychloroquine are unproven therapies for critical COVID-19 infection, and are not recommended. Providers should focus on interventions with demonstrated benefit, most notably steroids and good supportive/critical care.
Arabi YM, Gordon AC, Derde LPG, Nichol AD, Murthy S, Beidh FA, Annane D, Swaidan LA, Beane A, Beasley R, Berry LR, Bhimani Z, Bonten MJM, Bradbury CA, Brunkhorst FM, Buxton M, Buzgau A, Cheng A, De Jong M, Detry MA, Duffy EJ, Estcourt LJ, Fitzgerald M, Fowler R, Girard TD, Goligher EC, Goossens H, Haniffa R, Higgins AM, Hills TE, Horvat CM, Huang DT, King AJ, Lamontagne F, Lawler PR, Lewis R, Linstrum K, Litton E, Lorenzi E, Malakouti S, McAuley DF, McGlothlin A, Mcguinness S, McVerry BJ, Montgomery SK, Morpeth SC, Mouncey PR, Orr K, Parke R, Parker JC, Patanwala AE, Rowan KM, Santos MS, Saunders CT, Seymour CW, Shankar-Hari M, Tong SYC, Turgeon AF, Turner AM, Van de Veerdonk FL, Zarychanski R, Green C, Berry S, Marshall JC, McArthur C, Angus DC, Webb SA; REMAP-CAP Investigators. Lopinavir-ritonavir and hydroxychloroquine for critically ill patients with COVID-19: REMAP-CAP randomized controlled trial. Intensive Care Med. 2021 Aug;47(8):867-886. doi: 10.1007/s00134-021-06448-5. Epub 2021 Jul 12. PMID: 34251506; PMCID: PMC8274471.
Category: Orthopedics
Keywords: ketamine, analgesia, morphine (PubMed Search)
Posted: 7/24/2021 by Brian Corwell, MD
(Updated: 12/9/2024)
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Low dose ketamine was compared to morphine for the treatment of patients with long bone fractures
126 patients with upper and lower extremity long bone fractures were divided into two treatment groups
Pain scores were compared pre and at 10 minutes post treatment
Pain severity significantly decreased in both groups to a similar degree
Increase adverse effects (emergence phenomenon) noted in ketamine group but all effects resolved spontaneously without intervention.
Conclusion: Analgesic effect of ketamine is similar to morphine in patients with long bone fractures.
Majidinejad S, Esmailian M, Emadi M. Comparison of Intravenous Ketamine with Morphine in Pain Relief of Long Bones Fractures: a Double Blind Randomized Clinical Trial. Emerg (Tehran). 2014;2(2):77-80.
Category: Critical Care
Posted: 7/20/2021 by Mike Winters, MBA, MD
(Updated: 12/9/2024)
Click here to contact Mike Winters, MBA, MD
Hemophagocytic Lymphohistiocytosis (HLH)
Morrissette K, et al. Hemophagocytic lymphohistiocytosis in the emergency department: recognizing and evaluating a hidden threat. J Emerg Med. 2021;60:743-751.
Category: Pediatrics
Keywords: Bradycardia, intubation, RSI, atropine (PubMed Search)
Posted: 7/16/2021 by Jenny Guyther, MD
(Updated: 12/9/2024)
Click here to contact Jenny Guyther, MD
Kovacich et al. Incidence of bradycardia and the use of atropine in pediatric rapid sequence intubation in the emergency department. Pediatric emergency care. Published online 2021.
Category: Orthopedics
Keywords: Lower back pain, NSAIDs (PubMed Search)
Posted: 7/10/2021 by Brian Corwell, MD
(Updated: 12/9/2024)
Click here to contact Brian Corwell, MD
NSAIDs for lower back pain (LBP)
NSAIDs are recommended for first line treatment of lower back pain.
Ibuprofen (600mg), ketorolac (10mg) and diclofenac (50mg) were compared.
3 arm, double-blinded study in an ED population with musculoskeletal LBP.
66 patients in each arm.
Outcomes via telephone interview 5 days later
Primary outcome was improvement in Roland-Morris Disability Questionnaire (RMDQ).
Lower scores indicate better LBP functional outcomes.
Secondary outcomes: Pain intensity and the presence of stomach irritation.
Baseline characteristics similar in 3 groups.
Results: No significant differences between 3 arms in primary outcome.
Ibuprofen 9.4, ketorolac 11.9, and diclofenac 10.9 (p = 0.34).
Ketorolac group reported less overall pain intensity at day 5.
Ketorolac group reported less stomach irritation that the other drugs ((p < 0.01).
While there was no differences in terms of functional outcomes, there may be a benefit of using ketorolac in terms of overall pain intensity and stomach irritation. This would benefit from further study in a larger population in order to draw definitive conclusions.
Irizarry E, Restivo A, Salama M, Davitt M, Feliciano C, Cortijo-Brown A, Friedman BW. A randomized controlled trial of ibuprofen versus ketorolac versus diclofenac for acute, nonradicular low back pain. Acad Emerg Med. 2021 Jun 16. doi: 10.1111/acem.14321. Epub ahead of print. PMID: 34133820.
Category: Toxicology
Keywords: cannabis intoxication, trend, Canada, ICU admission, legalization (PubMed Search)
Posted: 7/8/2021 by Hong Kim, MD
Click here to contact Hong Kim, MD
Canada legalized recreational cannabis use in 2017. A retrospective study of children (0-18 years) who presented to pediatric ED with cannabis intoxication/exposure was performed between Jan 1, 2008 to Dec 21, 2019 to assess the trend/severity of intoxication.
Methods
Result
A total of 298 patients were identified
| Pre-legalization | Peri-post legalization | P value |
Monthly ED visit | 2.1 (IRQ: 1.9-2.5) | 1.7 (IQR: 1.0-3.0) | 0.69 |
ICU admission | 4.7% | 13.6% | 0.02 |
Respiratory symptoms | 50.9% | 65.9% | 0.05 |
Altered mental status | 14.2% | 28.8% | <0.01 |
Age < 12 years | 3.0% | 12.1% | 0.04 |
Unintentional exposure | 2.8% | 14.4% | 0.02 |
Edible ingestion | 7.8% | 19.7% | 0.02 |
Respiratory symptoms: tachypnea/bradypnea, cyanosis, O2 sat < 92%, bronchospasm, oxygen requirement
Conclusion
Cohen N et al. Pediatric cannabis intoxication trends in the pre and post-legalization era. Clin Toxicol 2021. e-pub Jun 17, 2021.
Category: Critical Care
Keywords: cardiac arrest, CPR, cardiopulmonary resuscitation, hands-off time, CCF, chest compression fraction (PubMed Search)
Posted: 7/6/2021 by Kami Windsor, MD
Click here to contact Kami Windsor, MD
Despite the knowledge that minimizing interruptions in chest compressions during CPR is key to maintaing coronary perfusion pressure and chance of ROSC,1-4 difficulties in limiting hands-off time remain.
Dewolf et al.5 recently performed a prospective observational study using body cameras to find that 33% (623/1867) of their CPR interruptions were longer than the recommended 10 seconds:
Previous studies have shown an increase in hands-off time associated with the use of cardiac POCUS during rhythm checks as well.6,7
Bottom Line: