Category: Orthopedics
Keywords: thrower, insability (PubMed Search)
Posted: 9/23/2018 by Brian Corwell, MD
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25yo baseball pitcher presents with medial elbow pain. He felt a painful “pop” and could not continue to throw (due to loss of speed and control). Mild paresethesias in 4th and 5th digits.
What physical examination maneuvers can you do at the bedside to assist in the diagnosis?
Exam opposite elbow first to establish baseline and to assist patient relaxation and understanding.
Flexing elbow to 20 to 30 degrees unlocks the olecranon
https://www.youtube.com/watch?v=KXQxH0UTn-8
https://www.youtube.com/watch?v=4sa9goJ4afs
or
https://www.youtube.com/watch?v=SwigwaZxBXE
https://www.youtube.com/watch?v=OnkkHpG3Dqg
Category: Pediatrics
Keywords: West syndrome, seizures (PubMed Search)
Posted: 9/21/2018 by Mimi Lu, MD
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Originally described a Dr. West in 1841 – it is a rare (~1200 cases annually) seizure disorder in young kids, generally less than 1 year old. Very subtle appearance, often with only bending forward or ‘jerking’ of the extremities as opposed to Brief Resolved Unexplained Event (BRUE) or tonic-clonic in description. The spasms can be thought of as a syndrome, where 70% of those have an undiagnosed rare metabolic/genetic disease.
A prompt evaluation, including labs, EEG, MRI, metabolic and genetic studies is vital in helping to establish a diagnosis which can have a profound impact on the patients prognosis. Examples might include Tuberous Sclerosis, Pyridoxine Dependent Seizures among over 50 others.
Bottom line: In pediatric patients less than 1 year old who present to the Emergency Department with a description of spasm-like episodes, consider Infantile Spasms on the differential, and consult your friendly neighborhood Pediatric Neurologist for help in determining a proper disposition.
http://www.childneurologyfoundation.org/disorders/infantile-spasms/
https://www.ninds.nih.gov/Disorders/All-Disorders/Infantile-Spasms-Information-Page
Category: Pediatrics
Keywords: Fever, pain control, ibuprofen, acetaminophen (PubMed Search)
Posted: 9/21/2018 by Jenny Guyther, MD
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Walsh P, Rothenberg S, Bang H. Safety of ibuprofen and infants younger than 6 months: A retrospective cohort study. PLos ONE 13 (6):e019493.
Category: Toxicology
Keywords: Anticholinergic, Plant (PubMed Search)
Posted: 9/20/2018 by Kathy Prybys, MD
Click here to contact Kathy Prybys, MD
A 19 year old male presents confused and very agitated complaining of seeing things and stomach pain. His friends report he ingested a naturally occurring plant to get high a few hours ago but is having a "bad trip". His physical exam :
Temp 100.3, HR 120, RR 14, BP 130/88. Pulse Ox 98%.
Skin: Dry, hot , flushed
HEENT: Marked mydriasis 6mm
Lungs: Clear
Heart: Tachycardic
Abdomen: Distended tender suprapubic with absent bowel sounds,
Neuro: Extremely agitated pacing, no muscular rigidity.
What has he ingested and what is the treatment?
Datura stramonium, aka: Jimson Weed, flowers in the summer with white to violet trumpet petals, green irregular toothed leaves, and a green thorny round walnut sized seed pod (aka: thorn apple) the base of the stem. In the fall, the seed pods turn brown and split open to reveal chambers that are packed with dozens of small black seeds containing the anticholinergic tropane alkaloids, atropine, hyoscyamine, and scopolamine.
All parts of the plant are toxic and it has long been used in traditional medicine. Toxicity consists of anticholinergic toxidrome: Delirium and agitation, visual hallucinations, dry flushed skin, hyperthermia, mydriaisis, tachycardia, absent bowel sounds, urinary retention, remembered by the pneumonic "Red as a beet, hot as a hare, dry as a bone, blind as a bat, mad as a hatter, the bowel and bladder lose their tone, and the heart runs alone" . Toxicity is usually 12 hours but can be quite prolonged.
Treatment consists of :
-Gastric decontamination with activated charcoal and whole bowel irrigation for seed ingestion (seeds get caught up in gastric folds prolonging toxicity)
-IV Physostigmine, a reversible short acting acetylcholinesterase inhibitor increases acetylcholine at the synaptic clef, crosses the blood brain barrier, and is antidotal. Physostigmine has been demonstrated to be more effective and without significant complications when compared with benzodiazepines for the diagnosis and treatment of anticholinergic agitation and delirium. Usual dose is 0.5-2 mg with repeat dosages as needed.
Category: Critical Care
Posted: 9/18/2018 by Mike Winters, MBA, MD
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Sedating Mechanically Ventilated Patients
Category: Pediatrics
Keywords: Concussion, minor head injury, traumatic brain injury, mTBI (PubMed Search)
Posted: 9/14/2018 by Mimi Lu, MD
Click here to contact Mimi Lu, MD
The Centers for Disease Control and Prevention recently released guidelines on the diagnosis and management of mild traumatic brain injury (mTBI**) among children. From 2005-2009, children made almost 3 million ED visits for mTBI. Based on a systemic review of the literature, the guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI.
Key Recommendations:
1. Do not routinely image patients to diagnose mTBI (utilize clinical decision rules to identify children at low risk and high risk for intracranial injury (ICI), e.g. PECARN)
2. Use validated, age-appropriate symptoms scales to diagnose mTBI
3. Assess evidence-based risk factors for prolonged recovery. No single factor is strongly predictive of outcome.
4. Provide patients with instructions on return to activity customized with their symptoms (see CDC Resources below)
5. Counsel patients to return gradually to non-sports activities after no more than 2-3 days of rest.
A wealth for information and tools for provder and families can be found at:
www.cdc.gov/HEADSUP (including evaluation forms and care plans for providers)
www.cdc.gov/traumaticbraininjury/PediatricmTBIGuideline.html
**Although concussion, minor head injury, and mBI are frequently used interchangeably, they have different connotations which allows for misinterpretation and confusion. The guideline recommends the clinical use of the single term mild traumatic brain injury. This is defined as "an acute brain injury resulting from mechanical injury to the head from external physical forces including: (1) 1 or more of the following: Confusion or disorientation, loss of consciousness for 30 minutes or less, posttraumatic amnesia for less than 24 hours, and/or other transient neurologic abnormality such as focal signs, symptoms, or seizure; (2) Glasgow Coma Scale score of 13-15 after 30 minutes post injury or later upon presentation for healthcare
Diagnosis and management of mild traumatic brain injury in children: A systemic review. Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, Turner M, Benzel EC, Suskuer SJ, Giza CC, Joseph M,Broomand C, Weissa B, Gordon W Wright DW, Moser RS, McAvoy K, Ewing-Cobbs L, Duaime AC, Putukian M, Holhouse B, Paulk D, Wade SL, Herig SA, HalsteadM, Keenan H, Choe M, Christia CW, Gusiewic K, Raksin PB, Gregory A, Mucha A, Taylor HG, Callahan JM, DeWtt J, Collins MW, Kirkwood MW, Ragheb J, Ellenbogen RG, Spinks TJ, Ganiats TG, Sabelhaus LJ, Altenhofen K, Hoffman , Getchius T, Gronseh G,Donnell Z, O'Connor RE, Timmons SD JAMA Pediatr 2018 Sept 4.
Category: Toxicology
Keywords: anaphylactoid reaction, IV NAC (PubMed Search)
Posted: 9/13/2018 by Hong Kim, MD
(Emailed: 9/14/2018)
Click here to contact Hong Kim, MD
Analphylatoid reaction is caused by non-IgE mediated histamine released. Intravenous N-acetylcysteine (NAC) infusion is well known to cause analphylatoid reaction. However, it’s incidence is unknown.
Recently, a large retrospective study of all patients who received 21-hour IV NAC in 34 Canadian hospitals (1980 to 2005) was performed.
Anaphylactoid reaction was documented in 528 (8.2%) of 6455 treatment courses
Over 90% patients developed analphylatoid reaction within 5 hours.
Onset of reaction:
Administered medication for treatment
Patient characteristics that were associated with higher incidence of Anaphylactoid reaction includes
Bottom line
Yarema M et al. Anaphylactoid reactions to intravenous N-acetylcysteine during treatment for acetaminophen poisoning. J Med Toxicol 2018: Jun;14(2):120-127. doi: 10.1007/s13181-018-0653-9. Epub 2018 Feb 8.
Category: Critical Care
Keywords: acidosis, acidemia, sodium bicarbonate, shock (PubMed Search)
Posted: 9/11/2018 by Kami Windsor, MD
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The recently published BICAR-ICU study looked at the use of bicarb in critically ill patients with severe metabolic acidemia...
Bottom Line:
Consider administration of sodium bicarbonate for your critically ill ED patients with severe metabolic acidosis and AKI, especially if acidosis &/or renal function is not improved with usual initial measures (such as IVF, etc).
*Acute Kidney Injury Network Staging Criteria
Jaber S, Paugam C, Futier E, et al. Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomised controlled, phase 3 trial. Lancet. 2018;392(10141):31-40.
Category: Orthopedics
Keywords: Ulnar nerve (PubMed Search)
Posted: 9/9/2018 by Brian Corwell, MD
(Updated: 9/18/2024)
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Froment’s Sign
Tests for motor weakness of the Ulnar nerve
Patient asked to hold piece of paper in both hands, grasping with the thumb and radial side of index finger of both hands
Examiner then pulls on the paper
Test is positive if patient flexes the thumb IP join in an attempt to hold onto paper
https://handlab.com/resources/wp-content/uploads/2014/04/June-2013-No25.jpg
Category: Critical Care
Posted: 9/4/2018 by Mike Winters, MBA, MD
(Updated: 9/18/2024)
Click here to contact Mike Winters, MBA, MD
Does Lactated Ringer's Raise Serum Lactate?
Zitek T, et al. Does intraveneous lactated ringer's solution raise serum lactate? J Emerg Med. 2018; 55:313-8.
Category: Geriatrics
Keywords: wounds, trauma, procedure (PubMed Search)
Posted: 9/3/2018 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS
Many elderly patients have thin skin making suture repair of lacerations difficult. Consider using Steri-Strips™ in combination with sutures to close fragile skin tears.
1. Apply Steri-Strips™ perpendicular to the wound in order to approximate skin edges.
2. Place sutures through both the applied Steri-Strips™ and skin and knot the suture.
This technique will help prevent the suture from tearing the skin as the tension of the suture will be distributed across the surface area of the Steri-Strips™.
Davis M, Nakhdjevani A, Lidder S. Suture/Steri-Strip Combination for the Management of Lacerations in Thin-Skinned Individuals. The Journal of Emergency Medicine. 2011;40(3):322-323. doi:10.1016/j.jemermed.2010.05.077.
Category: Pharmacology & Therapeutics
Keywords: Sepsis, Antibiotics, CMS, Core Measures (PubMed Search)
Posted: 9/1/2018 by Wesley Oliver
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The Centers for Medicare and Medicaid Services (CMS) require broad spectrum antibiotics to be administered within 3 hours of presentation of sepsis to be in compliance with the sepsis measure.
Not only do the antibiotics that are chosen determine compliance with this measure, but the order in which antibiotics are given can also significantly affect compliance.
According to CMS, for combination antibiotic therapy, both antibiotics must be started within the three hours following presentation; however, they do not need to be completely infused within this time frame.
Combination therapy typically includes a monotherapy antibiotic (see list in detailed information below) plus vancomycin (daptomycin or linezolid could also be used).
So which antibiotic should be given first?
If a monotherapy antibiotic is given first within the 3 hours of presentation, then compliance for the sepsis measure is met. These antibiotics cover a broader range of bacteria and are typically infused over ~30 minutes, which allows plenty of time for your second antibiotic to be initiated.
If vancomycin is given first, compliance with this measure can become difficult. First, vancomycin has a narrower spectrum of activity and is not a monotherapy antibiotic. Second, vancomycin infusion rates range from 1 to 2 hours. Given that antibiotics are usually given after sepsis is flagged, this infusion rate only gives a short period of time for the second antibiotic to be initiated. Thus, vancomycin should almost always be the second antibiotic infused.
In addition, patients may also have limited intravenous access or antibiotics may not be compatible with resuscitation fluids. All of these factors together must be considered when trying to gain compliance with this measure.
Take-Home Point:
Administer monotherapy antibiotics (e.g. piperacillin/tazobactam and cefepime) prior to administering vancomycin in your septic patients to improve compliance with the sepsis measure.
Specifications Manual for National Hospital Inpatient Quality Measures v5.4. The Joint Commission. https://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx. Updated December 29, 2017. Accessed August 31, 2018.
Category: Pediatrics
Posted: 8/31/2018 by Rose Chasm, MD
Click here to contact Rose Chasm, MD
Bachur, R. Comparison of acute treatment regimens for migraine in the emergency department. Pediatrics.2015;135(2)232-238.
Gelfand, A. Treatment of pediatric migraine in the emregency department. Ped Neuro.2012;47(4)233-241.
Kacperski, J. The optimal management of headaches in chidlren and adolescents. Ther Adv Neuro Disor. 2016;9(1)53-68.
Sheridan, D. Pediatric Migraine: Abortive treatment in the emergency department. Headache. 2014;54(2):235-245.
Category: Toxicology
Keywords: Weakness (PubMed Search)
Posted: 8/2/2018 by Kathy Prybys, MD
(Emailed: 8/31/2018)
(Updated: 8/31/2018)
Click here to contact Kathy Prybys, MD
A 68 year old male presents to the ED complaining of weakness to his legs. He states today his yard chores took him over 2 hours to complete instead of the usual 15-20 minutes due need to take frequent breaks for rest due to leg pain. He denied any chest pain or shortness of breath. Past medical history included hypercholesteremia, HTN, and CAD. He is taking aspirin and recently started on rosuvastatin.
His physical exam was unremarkable.
Results showed normal EKG and CBC. Bun was 70, Creatinine was 3.4, and CPK of 1025.
This patient has statin induced rhabdomyolysis and acute renal failure.
Take Home Points:
Category: Airway Management
Keywords: foot, necrosis (PubMed Search)
Posted: 8/26/2018 by Brian Corwell, MD
Click here to contact Brian Corwell, MD
Kohler’s disease
Osteonecrosis of the tarsal navicular bone
Affects children ages 4 to 7
4x more likely in males
Can be painless or present with arch/midfoot pain and a limp (usually activity related)
Usually unilateral but can be bilateral (in up to 25%)
PE: Tenderness to palpation over the length of the arch esp the medial navicular
Swelling, warmth, redness
-Can be misdiagnosed as an infection
X-ray: Sclerosis, collapse/flattening or fragmentation of navicular
Treatment: Walking boot or short leg cast
http://www.texasfootdoctor.org/images/kohlers%20xray.jpg
Category: Toxicology
Keywords: naloxone dose, recurrence of opioid toxicity (PubMed Search)
Posted: 8/23/2018 by Hong Kim, MD
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Various intial doses of naloxone (0.4 to 2 mg) are administered to reverse the signs and symptoms of opioid toxicity. However, there is limited data regarding the duration of action of naloxone is correlated to the administered dose.
A recently published retrospective study investigated whether initial naloxone doses (IV), low-dose (0.4 mg) vs. high-dose (1-2 mg), lead to different time to recurrence of opioid toxicity.
Study sample: 274 patient screened but 84 patients were included.
Higher rate of adverse effects (withdrawal symptoms - vomiting, agitation, tachycardia, etc.) were observed in high-dose group (41% vs. 31%) but this was not statistically signficant.
Conclusion:
Wong F et al. Comparison of lower-dose versus higher-dose invetravenous naloxone on time to recurrence of opioid toxicity in the emergency department. Clin Toxicol (Phila) 2018 Jul 23:1-6. doi: 10.1080/15563650.2018.1490420. [Epub ahead of print]
Category: Neurology
Keywords: shingles, weakness, infection (PubMed Search)
Posted: 8/22/2018 by Danya Khoujah, MBBS
(Updated: 9/18/2024)
Click here to contact Danya Khoujah, MBBS
Category: Critical Care
Posted: 8/21/2018 by Mike Winters, MBA, MD
Click here to contact Mike Winters, MBA, MD
Critical Post-Arrest Interventions
Walker AC, Johnson NJ. Critical care of the post-cardiac arrest patient. Cardiol Clin. 2018; 36:419-428.
Category: Pediatrics
Keywords: Sedation, NPO time, pediatrics (PubMed Search)
Posted: 8/17/2018 by Jenny Guyther, MD
(Updated: 9/18/2024)
Click here to contact Jenny Guyther, MD
Is there an association between pulmonary aspiration, vomiting or any serious adverse event and the preprocedural fasting time?
The odds ratio of any adverse event did not increase significantly with each additional hour of fasting duration for both solids and liquids.
The guidelines set by the American Society of Anesthesiology for fasting include a minimum of 2 hours for clear liquids, 4 hours for breast milk, 6 hours for formula and light meals and 8 hours for solid meals containing fatty foods or meat.
This was a secondary analysis of a multicenter prospective cohort study of children 0-18 years who received procedural sedation in 6 Canadian pediatric emergency departments from 2010-2015. 6183 children were included with 99.7% meeting ASA 1 or 2 categories. 2974 patients did not meet the American Society of Anesthesiology fasting guidelines for solids and 510 patients did not meet the fasting guidelines for liquids. The overall incidence of adverse events was 11.6%. There were no cases of pulmonary aspiration. There was a total of 717 adverse events. 315 events were vomiting. Oxygen and vomiting were the most common adverse events.
Association of Preprocedural Fasting with Outcomes of Emergency Department Sedation in Children. JAMA Pediatrics. Published online May 18, 2018.
Category: Critical Care
Keywords: Resuscitation, OHCA, prehospital medicine, cardiac arrest, epinephrine (PubMed Search)
Posted: 8/14/2018 by Kami Windsor, MD
(Updated: 9/18/2024)
Click here to contact Kami Windsor, MD
The highly-awaited PARAMEDIC2 trial results are in:
Interestingly, the authors also queried the public as to what mattered to them most:
Bottom Line:
A Few Things:
Perkins GD, Ji C, Deakin CD, et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2018. doi: 10.1056/NEJMoa1806842.