A 19 year old man presents with a scalp lesions/burns after an exposure to incendiary agent. His wounds were smoking and they flouresce under UV light.
What is the causative agent?
Bottom Line: Discussion of benefit/risk and financial incentive associated with head CT in mild TBI affects patient decision. Interestingly in this population studied, more than half of patients will elect to obtain a head CT even in a low-risk scenario.
As the debate regarding the pathophysiology and ventilator mechanics of COVID pneumonia rages on, it is important to have a method to evaluate the distensibility of patients' lungs so that we can minimize lung injury. It has been well shown that both under- and over-distention lead to acute lung injury and inducing or worsening ARDS.
One method to find the "best" level of PEEP is through the PEEP titration test (also called a Driving Pressure titration test). High Driving Pressure (DP), which is equal to Plateau Pressure - PEEP, has been shown to be associated with lung injury, and the minimal DP obtainable for a given patient while still meeting ventilatory goals is often an objective in the ICU (common DP goal is < 15 cm H2O). A PEEP titration is optimally done on paralyzed patients, although it can be used on sedated or very calm patients as a "best guess" approximation. It will not work well on agitated patients or those participating heavily in their ventilation. Be sure not to do this if you are not authorized to make vent changes, and always make sure to coordinate appropriately with your RT.
To perform a PEEP titration:
*Consider placing the patient on square waveform VC, as this will also allow evaluation of stress index (if patient is not participating). This can be skipped if not evaluating stress index
1) Make a table for yourself on a piece of paper where you can record PEEP, Plateau Pressure, Driving Pressure, Blood Pressure, and SpO2.
2) Write down the initial PEEP, BP, and SpO2. Clearly document for yourself that this is the initial PEEP, so you do not inadvertantly leave the vent on different settings at the end. Perform an inspiratory hold to measure a plateau pressure. Fill in DP by using the equation DP = Pplat - PEEP
3) Change the PEEP. You can either increase or decrease. If you have a suspicion that the patient is over or under distended, go towards optimal distention, but if unsure it is ok to guess. Usually we go by increments of 2 cm H2O. Wait about 20-30 seconds on the new PEEP.
4) Measure a new plateau pressure and calculate a new DP. At each step, write down the BP and SpO2 as well to ensure you are not generating decreased cardiac preload or derecruitment/hypoxia (keep in mind that due to pulse ox lag, you may not see hypoxia for up to a few minutes).
5) Repeat at a few different PEEP levels. Typically in more unstable patients who may not tolerate aggressive vent changes you may only want to check 2-3 levels of PEEP. In more stable patients or if concern for ongoing lung injury is high, you might check up to 5-6 different levels of PEEP. Please note that some COVID ARDS patients are so unstable that they will not tolerate any derecruitment, and this manuever should not be used in those patients as they could desaturate during the titration.
Once you have all of your data, consider changing to whichever PEEP level gives the lowest driving pressure. Keep in mind that while data from a PEEP titration can be very useful, it is only one data point and should be considered in combination with blood pressure, volume status, CXR findings, habitus, FiO2 weaning, and other factors. PEEP titrations should be reperformed periodically (usually daily in most semi-stable ICU patients, more often in unstable patients). it is also recommended to write a note in the chart with your initial vent settings, data from the titration, and settings upon termination of the titration -- and call your RT if you changed the vent settings.
Bottom Line: PEEP titration (aka Driving Pressure titration) aims to identify the PEEP level where (PPlat - PEEP) is minimal and may help reduce risk of ongoing lung injury in ventilated patients.
MRI for Concussion Testing in the ED
The increased sensitivity of MRI may have a role in detecting more subtle intracranial injuries.
135 patients with mild TBI were prospectively evaluated for acute head injury in emergency departments of 3 LEVEL I trauma.
27% of these patients with a normal initial head CT had an abnormal brain MRI including contusions and microhemorrhages. A greater number of these subtle findings was associated with neuropsychological defects on both short-term memory function and with poorer 3 month cognitive outcomes. Inherent difficulties of access, actionable results and reimbursement issues prevent application of MRI for concussion evaluation in the ED.
Note: Mild TBI defined as GCS 13-15 is not the same as sport or activity related concussion which I consider to be GCS 14-15.
Take home: There is currently no role for MRI in the acute evaluation of concussion in the ED.
If you have an intuition your patients older than 65 are at increased risk of infection, especially pneumonia (4-11 times the risk of the under 65 cohorts), you are correct.
If you are concerned your patients co-morbidities, such as COPD, heart disease, and malnutrition will contribute to prolonged mechanical ventilation (the rate of VAP increases 1-3% every extra day on the vent), you are correct.
After age 70, the ICU length of stay and duration of mechanical ventilation increase by 5 days and 9 days respectively.
In the age of COVID-19, itself associated with prolonged mechanical ventilation, it's fair to prepare patients and families for this. We are fortunate we do not need to ration ventilators, so our discussions remain centered on the wishes of our patients, informed by a realistic understanding of what treatment and recovery entail.
Short periods of AKI have been linked to prolonged hospitalizations, development of CKD/ESRD and in-hospital mortality. Historically, AKI in the ED has been studied with respect to the receipt of contrast media with little data available on nephrotoxic medications.
A recent 5-year retrospective cohort study sought to determine the impact of prescribing nephrotoxic medications in the ED and the development of AKI within 7 days defined as an increase in SCr of ≥ 0.3 mg/dL or 1.5 x baseline. The categories of potentially nephrotoxic medications included ACE-i/ARB, antibiotics, diuretics, NSAIDs, and other (antifungal, antineoplastic, and antivirals).
Inclusion: Adult patients ≥ 18 years, with an initial and repeat SCr measured 24-168h after the initial test, under admitted or observation status (discharged patients were included if they had a repeat SCr in the time window).
Exclusion: previous hospital or ED visit within 7 days, initial SCr < 0.4 mg/dL, initial SCr > 4.0 mg/dL, missing data, dialysis, or transplant history.
The authors assessed 46,965 hospitalized encounters and found that 13.8% of patients developed AKI. Risk factors included older age, African American patients, history of CHF or CKD, higher initial SCr, and higher complexity and mortality. AKI developed within 48 hours in half of the patients and the reminder did so by 120 hours. Approximately 22% had ≥ 1 potentially nephrotoxic medication administered and 6% had ≥ 2 classes.
Diuretics were associated with the highest risk of AKI (64% increased risk), followed by ACE-i/ARBs (39%), and antibiotics (13%). NSAIDs were not associated with an increased risk. The antibiotics associated with the highest risk of AKI were piperacillin-tazobactam, sulfamethoxazole-trimethoprim, and quinolones.
Bottom Line: Medications prescribed in the ED have an impact on the development of AKI during hospitalization. While these cannot always be avoided, use caution when combining multiple nephrotoxic medications and discontinue therapy early when feasible.
Recently, “disinfectants,” or germicides, has gain public attention during COVID-19 pandemic. So, what types of agents are considered as “disinfectants?”
Germicides as classified into three broad categories
1. Antiseptics – chemicals applied to living tissue to kill or inhibit microorganisms
a. Iodine & iodophors (e.g. Povidone-iodine; aka Betadine)
b. Chlorine, bleach (sodium hypochlorite)
c. Chlorhexidine
d. Hydrogen peroxide
e. Alcohols (ethanol and isopropanol)
2. Disinfectants – chemicals applied to inanimate objects to kill or inhibit microorganisms
a. Formaldehyde
b. Phenol (aka carbolic acid)
c. Substituted phenols (e.g. hexachlorophene; aka pHisoHex)
d. Quaternary ammonium compounds (benzalkonium chloride; aka Zephiran)
3. Sterilants – chemicals applied to inanimate objects to kill all microorganisms including spores
a. Ethylene oxide
b. Glutaraldehyde
Although ethanol is frequently found in alcoholic beverage and consumable, no other chemicals should be ingested or injected.
Vitamin C for Septic Shock?
Comparison of Oral Ibuprofen at Three Single-dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial
Ibuprofen is one of the most commonly used medications in the ED for the acute treatment of pain. Analgesic ceiling doses are not well supported. Some adverse effects of NSAIDs are dose dependent (GI and cardiovascular).
A recent study looked to compare the analgesic effect of oral ibuprofen at 3 different doses
Population: Adult ED patients (aged 18 and older) with acute pain.
Methods: Randomized double-blind trial.
Goal: To examine the efficacy of ibuprofen at 400, 600 and 800mg.
Only 225 patients enrolled (75 per group). Outcome was difference in pain scores at 60 minutes.
Results: Difference in mean pain scores at 60 minutes between 400 and 600mg (0.14), 400 and 800mg (0.14) and 600 and 800mg (0.00).
Conclusion: Reduction in pain scores was similar between all 3 dosing groups. Consider lower dosing of ibuprofen in ED patients presenting with acute pain.
This analgesic ceiling dose is lower than recommended by the FDA and most EM textbooks.
Consider using the 400mg ibuprofen dose for ED patients with acute pain
Bottom Line: Cervical collars can increased ICP in moderate-severe TBI. In patients with poor cerebral compliance and impaired cerebral autoregulation, even a small increase in ICP can affect cerebral perfusion.
Buprenorphine (BUP) is increasingly prescribed/used to treat opioid use disorder (OUD) in the United State. BUP is mainly metabolized by CYP3A4 where its enzymatic activity can be either induced or inhibited by many agents.
For example, a study showed that Rifampin administration for 15 days, a potent 3A4 inducer, resulted in (1):
On the contrary, exposure to voriconazole – strong 3A4 inhibitor - resulted in (n=12 health volunteers) (2):
Cannabis use – (CBD is a CYP 3A4 inhibitor) also increased the BUP concentration by 2.7 fold. (3)
Bottom line:
Title: Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus
Settings:
Patients:
Intervention:
Comparison:
Outcome: absence of clinical seizure at 60 minutes after infusion of medication.
Study Results:
Discussion:
Conclusion:
The leading cause of death in the US for those aged 16 to 24 years is motor vehicle collisions (MVCs). Teen drivers are more likely than any other age group to be involved in an MVC that result in injury or fatality. Texting while driving, nighttime driving, inexperienced driving, and driving under the influence of alcohol or drugs may play a role in these collisions.
Can anticipatory guidance related to safe driving be done in the ED? YES!
This study implemented a toolkit that contained a copy of the driving law, a sample parent-teen driving contract and statistics on teen driving injuries. Post toolkit questionnaires showed that both teens and their guardians learned new information.
Bottom line: Engage in anticipatory guidance in the ED with teens and their parents about seatbelt use, the dangers of driving under the influence and local driving laws.
Clinical Question: Does a lower MAP target (60-65 mmHg) for ICU patients ≥ 65 years-old reduce 90-day mortality?
Methodology:
-Design: multicenter (across 65 UK ICUs), randomized clinical trial (not blinded), ultimately with 2598 patients
-Inclusion criteria: ICU patients ≥ 65 years-old receiving vasopressors for vasodilatory hypotension with adequate fluid resuscitation
-Exclusion criteria: vasopressors being solely used for bleeding or acute RV/LV failure or post-cardiopulmonary bypass vasoplegia, ongoing treatment for brain/spinal cord injury, death perceived as imminent
-Intervention:
Results:
-Patients in the permissive hypotension group had a lower exposure to vasopressors compared with those in the usual care group
-Mean MAP was on average 6 mmHg lower in permissive hypotension group
-At 90 days, there was no statistically significant difference in all-cause mortality
-No significant difference in mean duration of ICU and hospital stay, duration and days alive and free from advanced respiratory and renal support to day 28
-No significant different in number of serious adverse events (severe acute renal failure, supraventricular and ventricular cardiac arrhythmia, myocardial injury, mesenteric ischemia, and cardiac arrest)
Bottom line:
A lower MAP goal of 60-65 mm Hg appears to be safe for ICU patients ≥ 65 years-old being treated for vasodilatory hypotension
A recent study looked at
Back pain is the most common pain complaint worldwide
-Accounted for about 9% of all ED visits.
Summary: ED use of tramadol for back pain doubled from 2007 to 2016 despite an overall decrease in opioid use (in that period)
Tramadol -- either administered in the ED or prescribed -- was used in 8.4% of back pain visits in 2016, up from 4.1% in 2007 (P=0.001).
In 2007, overall opioid use was 53.5%; in 2016, it was 46.5% (P=0.001). The largest drop was in hydrocodone use.
A recent study in JAMA looked at the risk of death in 90,000 people one year after filling a Rx for tramadol vs. one of several other analgesics such as naproxen, diclofenac or codeine.
All patients were aged 50 years or older and has osteoarthritis.
Initial Rx for tramadol was associated with a higher rate of mortality than with NSAIDs (but not compared to codeine).
There is currently a high, and appropriate, concern regarding the aerosolization of viral particles during various methods of respiratory support. While studies are limited, here is some of the currently available data (mostly-simulated) on the approximate maximum distances of particle spread:
Nasal Cannula 5LPM:1 1 ft 4.5 in
Non-Rebreather Mask, 6-12LPM: 4 in, minimal change with increasing flows1
High Flow Nasal Cannula
CPAP (20 cmH2O) provided by oronasal mask with good fit (leak from exhaust port):2 11.5 in
Bilevel positive airway pressure w/ oronasal mask (IPAP 10-18/EPAP 4): max dispersal:4 1 ft 7.7 in
Bilevel positive airway pressure with full facemask5 (IPAP 18 / EPAP 5): 2 ft 8 in
Bilevel positive airway pressure with helmet:4
Utility of Surgical Mask:6
Bottom Line:
In vivo data from actual patients is lacking, however there is potentially lower risk of aerosol spread with HFNC than regular nasal cannula, perhaps due to higher likelihood of a tighter nare/nasal cannula interface. Nonrebreather mask performs well indirectly with the shortest dispersal distance. Noninvasive positive pressure ventilation with an oronasal mask and good seal has a relatively short dispersal distance, and a surgical mask over respiratory support interventions actively decreases amount, if not distance, of particle spread. Use of appropriate PPE and negative pressure rooms, if available, remains key.
A 7 year-old Spanish speaking female presents to the emergency room after ingestion of 2 – 3 tablets of her sister’s medication. She complains of nausea/vomiting with diarrhea, periorbital/facial swelling, and flushing of her skin. Her urine is reddish but there is no blood is shown in urinalysis/urine microscopic analysis. The patient's sister is taking the medication for a respiratory condition.
Which medication did she take?
Cyclopeptides (Amatoxin)-containing mushroom poisoning results in delayed development of gastrointestinal symptoms that may progress to liver failure. There is no established antidotal treatment for cyclopeptide-induced hepatic failure; silibinin is currently under investigation.
There is a wide range of case fatality reported from cyclopeptides-containing mushroom poisoning: 4.8% to 47%.
National Poison Data System was reviewed from 1/1/2008 to 12/31/2018 for all suspected cyclopeptides containing mushroom poisoning. Out of 8953 suspected cases, 148 cases were included in the study.
Results:
Therapy:
Case fatality
Conclusion:
Please see Part I from 12/24/19 for information about causes and symptoms.
Diagnosis:
The diagnosis of HLH is challenging, as it often mimics sepsis or other critical illness. A high index of suspicion is vital and early treatment, imperative.
Diagnostic criteria in adults include 5 of 8 of the following:
(based on the Hscore: https://www.mdcalc.com/hscore-reactive-hemophagocytic-syndrome#use-cases)
· Presence of known immunosuppression
· Fever >38.5
· Splenomegaly or hepatomegaly
· Cytopenias
· Ferritin elevation (usually markedly elevated)
· Elevated triglycerides
· Low fibrinogen level
· ALT elevation
Immunologic testing:
· CD25 levels are elevated
· NK cell activity is low or absent
In adults, highly elevated ferritin levels (>10,000) are highly suggestive of HLH.
Elevated LDH, Ddimer, and multisystem organ dysfunction (especially CNS) is common.
Immunologic testing should not delay treatment if other lab values suggestive of HLH.
Treatment:
Given the high mortality rate, treatment should be initiated if the symptoms are suggestive of HLH. In the setting of a critically ill individual, hematology consultation is warranted for treatment guidance as treatment is based on lab values and clinical picture. Treatment usually starts with high dose , IV steroids (dexamethasone) and may include chemotherapeutic agents, such as Etoposide. For those patients with CNS involvement, intrathecal chemotherapy is usually a mainstay of treatment
Studying the demographics of all both sports and recreation related injuries is important for the development of effective preventive strategies.
Methods: National electronic injury surveillance system all injury program from 2005 to 2013 (367,300 sports and recreation related ED visits).
18 common sports and recreational activities in the United States
Results: A fracture occurred in 20.6% and a joint dislocation in 3.6% in ED visits for a sport related visit
Most of the fractures occurred in football (22.5%) and occurred in autumn and summer. Most fractures occurred in arm/hand (finger most common). Most fractures occurred in school or sporting venues.
The OR for fracture was greatest for inline skating (6.03), males (1.21) and those between 10 and 14 years of age and those older than 84 years (4.77).
Dislocations were highest in basketball (25.7%) and occurred in the autumn and on weekends. Most dislocations occurred in school or sporting venues.
The OR for dislocation was greatest in gymnastics (4.08), males (1.50) and those aged 20 to 24 years (9.04)
The most common fracture involved the finger and the most common dislocation involved the shoulder, followed by finger and knee.
