UMEM Educational Pearls

Hyperoxia and the Post-Arrest Patient

  • Current post-arrest guideilnes recommend titrating supplemental O2 to avoid hypoxia and limit exposure to hyperoxia.
  • Importantly, these recommendations are based primarily on retrospective studies that have used ABG values within the first 24 hours following ROSC.
  • The latest study to evaluate the impact of hyperoxia following cardiac arrest was just published in Circulation
  • This study is a prospective, cohort study that evaluated the association between early hyperoxia and poor neurologic outcome in adults following cardiac arrest. (ABGs were obtained at 1 hour and 6 hours following ROSC)
  • Of 280 patients, 38% were exposed to early hyperoxia (defined as a PaO2 > 300 mm Hg)
  • Take Home Points
    • Early hyperoxia was found to be an independent predictor of poor neurologic outcome at hospital discharge.
    • One hour longer duration of hyperoxia was associated with a 3% increase in the risk of poor neurologic outcome
    • SaO2 could not reliably exclude the presence of hyperoxia.

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Category: Geriatrics

Title: Geriatric Dizziness (Submitted by: Dr. Katherine Grundmann)

Keywords: dizziness, CT, MRI, Cerebellar (PubMed Search)

Posted: 2/5/2018 by Danya Khoujah, MBBS (Updated: 6/22/2018)
Click here to contact Danya Khoujah, MBBS

15% of older adults presenting to ED for dizziness have serious etiologies; 4-6% are stroke-related and sensitivity of CT for identifying stroke or intracranial lesion in dizziness is poor (16%), so if CNS etiology suspected, seek neuro consult or MRI (83% sensitivity)

 

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Takeaways

Debating between cefepime or piperacillin/tazobactam for your septic patient? Use this table to help you decide.

 

 

Cefepime

Piperacillin/Tazobactam

Gram Negative Spectrum

Pseudomonas aeruginosa 

Yes

Yes

Aerobic gram negative organisms 

E. coli 

Klebsiella sp. 

Proteus mirabilis 

M catarrhalis  

H. influenza 

E. coli 

Klebsiella sp. 

Proteus mirabilis 

M. catarrhalis 

H. influenza 

Anerobic gram negative organisms 

No

B. fragilis 

 

Gram Positive Spectrum

MRSA 

No

No

Aerobic gram positive organisms 

MSSA 

CoNS 

Group A Strep 

S. pneumoniae 

 

MSSA 

CoNS 

Group A Strep 

S. pneumoniae 

E. faecalis 

Anaerobic gram positive organisms 

P. acnes 

Peptostreptococci 

P. acnes 

Peptostreptococci 

Clostridium sp. 

Infection Site Concerns

CNS Penetration 

Yes

No1

Urine Penetration 

Yes

Yes

Lung Penetration 

Yes

Low2

Dosing Frequency (Normal Renal Function)

Q8h 

Q6h 

1Tazobactam CNS penetration is limited, thus limiting antipseudomonal activity in the CNS 

2. Low pulmonary penetration, may not achieve therapeutic levels in patients with critical illness 

 

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Category: Pediatrics

Title: Name that Belly Pain!

Keywords: Pediatrics, Abdominal Pain (PubMed Search)

Posted: 2/2/2018 by Megan Cobb, MD
Click here to contact Megan Cobb, MD

Question

Your patient is an18 months old female with intermittent abdominal pain for the last 4-5 days. She has history of constipation and soy allergy, seen at an outside hospital three days ago for the same. She had an xray and was discharged home with instructions for at home clean out with diagnosis of constipation. 

Mother is bringing her to your ED because the pain is back. The laxatives helped somewhat, but her symptoms have returned. She reports that the patient cries spontaneously, lasting 1-2 minutes, then completely resolves. These episodes happen at multiple times during the day. 

ROS: Decreased appetite and energy, but NO fevers, vomiting, diarrhea, bloody stool, abdominal distension, hematuria, or lethargy. 

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Attachments

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Category: Toxicology

Title: Perils of OTCs

Posted: 2/1/2018 by Kathy Prybys, DO (Emailed: 2/2/2018) (Updated: 2/2/2018)
Click here to contact Kathy Prybys, DO

Question

47 year old woman presents with cough, headache, weakness, and low grade fever. Her symptoms have been present for several days. Vital signs are temperature 99.9 F, HR 96, RR 16, BP 140/88, Pulse Ox 98%.  Physical exam is nonfocal. She is Influenza negative. She is treated with Ibuprofen and oral fluids.  Upon discharge she mentions she is having difficulty hearing and feels dizzy. Upon further questioning she admits to ringing in her ears. What tests should you order?

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Category: Critical Care

Title: Is there a benefit to steroids in septic shock?

Keywords: sepsis, septic shock, glucocorticoids, steroids, hydrocortisone (PubMed Search)

Posted: 1/29/2018 by Kami Hu, MD (Emailed: 1/30/2018)
Click here to contact Kami Hu, MD

As hospital volumes increase and ED patient boarding becomes more commonplace, emergency physicians may find themselves managing critically ill patients beyond the initial resuscitation.

The benefit of glucocorticoids in critically ill patients with septic shock has remained a topic of controversy for decades due to conflicting studies, including the 2002 Annane trial and the 2008 CORTICUS trial, which had opposing results when it came to the mortality benefit of steroids.

The results of the eagerly-awaited ADRENAL trial, a multicenter randomized controlled trial investigating the benefit of steroids in septic shock, were released earlier this month:

  • 3658 patients from 69 different medical and surgical ICUs
  • Adults with septic shock requiring mechanical ventilation (including noninvasive) and vasopressors/inotropes for at least 4 hours
  • Continuous infusion hydrocortisone 200mg/day vs placebo for 7 days or until ICU discharge, if shorter
  • No mortality benefit at 90 days (primary outcome) or at 28 days (secondary outcome)
  • Other secondary outcomes:
    • Hydrocortisone group = Shorter ICU LOS, shorter duration of shock, shorter duration of initial mechanical ventilation, fewer # of patients receiving a blood transfusion
    • No difference in: mortality at 28 days, hospital LOS, recurrence of shock, total vent-free days, mean volume of blood transfused in patients receiving blood products, use of renal replacement therapy, development of new bacteremia/fungemia

 

Take Home Points:

1. Administration of standard daily dose hydrocortisone by infusion does not seem to affect mortality in septic shock.

2. Emergency providers should continue to consider stress-dose steroids in patients with shock and a high risk of adrenal insufficiency (e.g., chronic steroid therapy, genetic disorders, infectious adrenalitis, etc).  

 

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Category: Orthopedics

Title: Dental Avulsion in the field/sporting event

Keywords: Dental avulsion, tooth, trauma (PubMed Search)

Posted: 1/27/2018 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Dental Avulsion in the field/sporting event

 

-  Only replace avulsed secondary teeth

-  Handle the tooth by the crown only

-  Rinse tooth with cold running water gently (the root should not be wiped)

-  Immediate attempt to reimplant permanent tooth into socket by 1st capable person:

*  Time is tooth: Each minute tooth is out of socket reduces tooth viability by 1%

*  Best chance of success if reimplant done within 5–15 min*?  Poor tooth viability if avulsed for >1 hr

-  If unsuccessful, place tooth in a transport solution (from most to least desirable):

Hanks balanced salt solution (HBSS)

*  Balanced pH culture media available commercially in the Save-A-Tooth kit

*  Effective hours after avulsion

Cold milk:

*  Best alternative storage medium

*  Place tooth in a container of milk that is then packed in ice (prevents dilution)

Saliva:

*  Store in a container of parent or child's saliva

-  Never use tap water or dry transport


Category: Neurology

Title: Brain Tumor Imaging 101

Keywords: edema, hemorrhage, tumor, CT, MRI, contrast (PubMed Search)

Posted: 1/24/2018 by Danya Khoujah, MBBS (Updated: 6/22/2018)
Click here to contact Danya Khoujah, MBBS

Although MRI is more sensitive for identifying tumors of the CNS, CT is usually the first line imaging modality in the ED. Some pearls:

  • Hyperattenuation = bright = dense (blood)
  • Hypoattenuation = dark = radiolucent (fluid, air, lipid, scar)
  • Masses that are darker + increased volume or mass effect = edema (image 1)
  • Masses that are darker + decreased volume = scar tissue or atrophy (image 2)
  • Masses that are bright + edema = hemorrhage (image 3)
  • Adding IV contrast improves detection of tumors: abnormal enhancement from disruption of blood brain barrier, necrosis or increased vascularity. (Image 4)

Image 1 Courtesy of Radiopedia.orgImage 2: courtesy of Dr Chris O'Donnell, Radiopaedia.orgImage 3: courtesy of Dr David Cuete, Radiopaedia.orgImage 4: Courtesy of David Kernick, and Stuart Williams Br J Gen Pract2011;61:409-411

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Category: Pediatrics

Title: Oral morphine versus ibuprofen in postoperative orthopedic pain in children

Keywords: Pain control in children, opiates, NSAIDS, motrin, orthopedic (PubMed Search)

Posted: 1/19/2018 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

This was a randomized superiority trial of 0.5mg/kg of oral morphine every 6 hours to 10 mg/kg of ibuprofen every 6 hours in children 5-17 years old who had minor outpatient orthopedic surgeries.  There were 77 patients in each group.  Primary outcome was pain as rated on the Faces pain scale.  Secondary outcomes were additional analgesic requirements, adverse events, and unplanned visits to the doctor.

Bottom line: Oral morphine was not superior to ibuprofen and both drugs decreased pain with no difference in efficacy.  Morphine was associated with more adverse events.

 

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Category: Toxicology

Title: Liver dialysis for poisoning-MARS therapy

Keywords: Liver dialysis, MARS (PubMed Search)

Posted: 1/18/2018 by Kathy Prybys, DO (Emailed: 1/19/2018) (Updated: 1/19/2018)
Click here to contact Kathy Prybys, DO

Acute liver failure carries a high morbidity without liver transplantation. Liver support systems can act as “bridge” until an organ becomes available for the transplant procedure or until the liver recovers from injury. Artificial liver support systems temporally provide liver detoxification utilizing albumin as scavenger molecule to clear the toxins without providing synthetic functions of the liver (coagulation factors). One of the most widely used devices is the Molecular Adsorbent Recirculating System (MARS).This system has 3 different fluid compartments: blood circuit, albumin with charcoal and anion exchange column, and a dialysate circuit that removes protein bound and water soluble toxins with albumin.

  • Mars has been used in several case reports to treat acetaminophen, Amanita phalloides,Phenytoin, lamotrigine, theophylline, and calcilum channel blockers poisonings.
  • All the extracorporeal liver assist devices are able to remove biological substances (ammonia, urea, creatinine, bilirubin, bile acids, amino acids, cytokines, vasoactive agents) but the real impact on the patient's clinical course has still to be determined.

Bottom Line

MARS therapy could be a potentially promising life saving treatment for patients with acute poisoning from drugs that have high protein-binding capacity and are metabolized by the liver, especially when concomitment liver failure. Consider consultation and transfer of patients to liver center.

 

 

 

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Category: Orthopedics

Title: Concussion Where are we now?

Keywords: Head injury, concussion, sideline (PubMed Search)

Posted: 1/13/2018 by Brian Corwell, MD (Updated: 6/22/2018)
Click here to contact Brian Corwell, MD

Concussion – Where are we now?

The Sport Concussion Assessment Tool 5th edition (SCAT 5) was released in 2017

It is a standardized tool to assist health care professionals in the evaluation of sport associated concussions

It should be used for those 13 years and older (there is a child version for younger athletes)

Print and bring to the sideline for your next coverage event!

http://bjsm.bmj.com/content/bjsports/early/2017/04/26/bjsports-2017-097506SCAT5.full.pdf

Some points to consider:

It should take at least 10 minutes to complete. Any less and you may not be performing the test correctly

The SCAT5 is the standard tool used in concussion assessment in the NCAA and NFL and other professional sports

Some symptoms of concussion appear over time. For example, an athlete may have zero or minimal symptoms immediately after yet be considerably symptomatic in 10 to 15 minutes.

               -Follow up screening evaluations are essential even in those with a negative initial sideline screening test

The SCAT5 should be used immediately after injury

               -Utility decreases post injury after days 3-5

               -The included symptom checklist has utility in tracking recovery

               -Attempt to perform in an environment free of distractions (crowd noise, bad weather)

The clinical utility of the SCAT5 can be enhanced by adding assessment of other factors such as reaction time, balance assessment, video-observable signs (if available) and oculomotor screening.


Tongue laceration is a common injury in children - occurring in the setting of falls and seizures. The most common location is the anterior dorsal portion of the tongue. Priorities are to evaluate for airway compromise (swelling, hematoma, bleeding) and retained foreign bodies (teeth fragments, etc). The vast majority of lacerations DO NOT require repair and do well with routine dental hygiene and antiseptic mouth wash. While there is no clear consensus for indications to repair, considerations include uncontrolled bleeding, airway compromise, wounds greater than 2 cm, and wounds that gape while the tongue is still in the mouth. Use large absorbable sutures (like 4-0 chromic gut). Check out this great video from EM:RAP - https://youtu.be/h14KyO8JlZE

Category: Toxicology

Title: Benefit of activated charcoal in large acetaminophen ( >= 40 gm) overdose.

Keywords: activated charcoal, large acetaminophen overdose, NAC dose (PubMed Search)

Posted: 1/11/2018 by Hong Kim, MD, MPH (Updated: 6/22/2018)
Click here to contact Hong Kim, MD, MPH

Acetaminophen (APAP) overdose is the leading cause of liver failure in the U.S. and Europe. Large APAP ingestion can result in hepatotoxicity despite the early initiation of n-acetylcysteine (NAC). 

A recently published study from Austrialia investigated the effect of activate charcoal and increasing the NAC dose for large APAP overdose patients (3rd bag: 100 to 200 mg/kg over 16 hours) during first 21 hours of NAC therapy

acetaminophen ratio (first APAP level taken between 4 to 16 hour post ingestion / APAP level on the Rumack nomogram line at that time point) was determined to compare APAP levels at different time points among study sample

e.g.  

first APAP level at 4 hour post ingestion = 400

APAP level on the Rumack APAP nomogram at 4 hour post ingestion = 150

APAP ratio = 400/150 = 2.67

 

Findings:

  1. Activated charcoal (AC): if given within 4 hours, AC significantly decreased the APAP ratio (OR: 1.4 vs. 2.2)
  2. Increased dose of NAC during the first 21 hour significantly decreased the risk of hepatotoxicity (OR: 0.27; 95% CI: 0.08 - 0.94).

 

Conclusion: 

  1. Administration of AC in patients with history of large APAP overdose (>=40 gm) within 4 hour of ingestion can still be beneficial.
  2. Increasing NAC dosing (3rd bag in first 21 hour thearpy) may decrease the risk of hepatotoxicity. 

Note: Any increase in NAC dosing from the standard 21 hour therapy should be performed after consulting your regional poison center.

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Category: Neurology

Title: Reversible Cerebral Vasoconstriction Syndrome (RCVS)

Keywords: RCVS, thunderclap headache, migraine, SAH (PubMed Search)

Posted: 1/10/2018 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

  • Reversible cerebral vasoconstriction syndrome (RCVS) is the second most common cause of thunderclap headache after aneurysmal subarachnoid hemorrhage (SAH) and the most common cause of recurrent thunderclap headaches.
  • Up to 40% of patients with RCVS have a history of migraine.
  • It is associated with selective serotonin reuptake inhibitors (SSRIs), triptans, cocaine, marijuana, tacrolimus, oral contraceptives, as well as the peripartum period.
  • Symptoms are often triggered by emotional stress, sexual activity, showering, straining, and physical exertion.
  • Although the vasoconstriction is reversible, it can cause intracranial hemorrhage, seizures, stroke, and coma.
  • Diagnosis is by history, cerebral angiography and exclusion of aneurysmal SAH.

Bottom Line: Consider RCVS in the differential of thunderclap headache and in patients who present with worse than usual migraine headache.

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Category: Critical Care

Title: Septic Cardiomyopathy

Posted: 1/9/2018 by Mike Winters, MD (Updated: 6/22/2018)
Click here to contact Mike Winters, MD

Septic Cardiomyopathy

  • Cardiac dysfunction is common in patients with sepsis.
  • Though mulitiple definitions exist, sepsis cardiomyopathy (SCM) is generally defined as an "acute syndrome of cardiac dysfunction that is unrelated to ischemia in patients with sepsis".
  • Depending on the study, the incidence of SCM ranges anwywhere from 7% to 70%.
  • Risk factors for SCM include:
    • Male
    • Younger age
    • High lactate at admission
    • History of heart failure
  • The best approach to treating patients with SCM is to maximize your treatment of sepsis.
  • Dobutamine is no longer routinely recommended for SCM based solely on measurements of ScvO2.

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Takeaways

Patients with severe asthma exacerbations that are unresponsive to inhaled beta-agonists may require the use of epinephrine to control their symptoms.  When patients get to this point what route of administration should be used for the administration of epinephrine?

The most recent asthma guidelines (published in 2007) recommend the use of SubQ epinephrine 0.3-0.5 mg every 20 minutes for 3 doses.  Drug references typically list SubQ or IM epinephrine 0.01 mg/kg (~0.3-0.5 mg) every 20 minutes as appropriate routes of administration.  There is currently no data demonstrating that one route of administration is better than the other in patients with asthma; however, in other disease states, such as anaphylaxis, IM epinephrine is preferred due to the more rapid and reliable absorption over SubQ administration.

Auto-injectors that administer IM epinephrine 0.3 mg are available.  These auto-injectors may decrease the risk of medications error; however, they can be expensive.  SubQ administration requires the use of a syringe and a vial/ampule of 1 mg/mL epinephrine.

Bottom Line: Either SubQ or IM epinephrine administration is appropriate for patients with severe asthma exacerbations.  The preferred method at a given institution will be dictated by historical practice, risk of medication dosing errors, and drug cost.

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Takeaways

A recent study was undertaken to validate the 4A's Test for the assessment of delirium in the elderly, with particular focus on inpatient geriatric patients; it revealed that the tool had high sensitivity in detecting delirium, particularly in those with dementia or language barriers, in whom this diagnosis can often be difficult to make.  Further studies would be useful in a similar demographic of emergency department geriatric patients to confirm that this straightforward test is generalizable to the emergency department geriatric patient population.

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Category: Pediatrics

Title: In NAT, suspicion is key.

Keywords: NAT, non-accidental trauma, abusive head trauma, intra-abdominal injury, burns (PubMed Search)

Posted: 1/6/2018 by Megan Cobb, MD
Click here to contact Megan Cobb, MD

Takeaways

In addition to suspicion of NAT with traumatic brain injury and burns, remember these other high risk injuries and features:

- Duodenal injuries in children <4 y/o 

- Frena injuries in non-ambulating children

- Proximal and midshaft humeral fractures > supracondylar fractures 

- Any bruising on the trunk, ears, neck, or with larger size or pattern  

- Delay in seeking care, inconsistent history, mechanism inconsistent with developmental age, and blame of a sibling or other child inflicting harm are all historical features also high risk. 

 

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Category: Critical Care

Title: Peri-Intubation Cardiac Arrest

Keywords: endotracheal intubation, cardiac arrest, airway, respiratory failure (PubMed Search)

Posted: 1/2/2018 by Kami Hu, MD (Updated: 1/4/2018)
Click here to contact Kami Hu, MD

Although the data is limited, current published rates of in-hospital, non-operating room peri-intubation cardiac arrest (PICA) range from 2 to 6%.1,2,3

Several risk factors associated with PICA have been identified and include:

  • Preintubation hemodynamic instability (shock index ≥ 1 or systolic blood pressure < 90mmHg)1,2,3
  • Elevated Body Mass Index (and increased risk with every 10kg body weight)1
  • Use of succinylcholine as paralytic3
  • Intubation occurring within one hour of nursing shift change3

Other common findings:

  • Most PICA occurs within 10 minutes of rapid sequence induction (RSI)1,2
  • PEA is the initial recorded rhythm 80-100% of the time.1,2,3
  • Even if ROSC obtained, PICA is associated with higher rates of in-hospital mortality compared to patients requiring emergent intubation who do not experience cardiac arrest.1,2,3

 

Bottom Line:  Endotracheal intubation is one of the riskiest procedures we regularly perform as emergency physicians.

  • Resuscitate hypotensive patients prior to or concomitantly with RSI and/or have a vasopressor at the ready in patients with higher risk of cardiovascular collapse.
  • Consider use of vecuronium or rocuronium, rather than succinylcholine, in patients who require a paralytic for intubation but are at higher risk of hyperkalemia or have an unknown history. 

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Category: Pediatrics

Title: Pediatric Cervical Spine Injuries

Posted: 12/29/2017 by Rose Chasm, MD (Updated: 6/22/2018)
Click here to contact Rose Chasm, MD

Children less than 8 years, and especially infants, are more susceptible to upper cervical spine injury.  Moreover, validated decision rules for suspected cervical spine injury imaging have not been proven to be as sensitive or specific for children less than 8 years of age.

The pediatric cervical spine has greater elasticity of the ligamentous structures, while the cartilaginous structures are less calcified. An infant's neck musculature is underdeveloped, with a disproportionally large head.  These factors increase the risk of cervical spine injury, and can make it difficult to properly place protective cervical collars in infants while assessing them for injury. 

In very young children, consider placing padding under the shoulders to prevent abnormal flexion that can occur with placement of a cervical collar, and consider having a lower threshold to image if mechanism history or exam is concerning.

Children are not little adults!  Clinicians must acknowledge the anatomic differences, varying age-related ability to cooperate with examination, pediatric specific injury mechanisms, and decreased reliability of validated decision rules for imaging in children, especially when younger than 8 years old.

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