Category: Critical Care
Keywords: Central venous catheter, ultrasound (PubMed Search)
Save time by using bedside ultrasound to confirm above-the-diaphragm central venous catheter (CVC) placement rather than waiting for chest x-ray confirmation:
1. Perform rapid push of saline (it doesn’t have to be agitated) through CVC while cardiac probe is placed with right atrium in view. Immediate visualization of bubbles (or “atrial swirl”) essentially confirms correct placement.
2. Perform the usual search for ipsilateral lung-sliding and the waves-on-the-beach to rule out procedural pneumothorax.
It makes sense that it’s going to be faster for you to use that internal jugular/subclavian central venous catheter (CVC) you just placed if you confirm with bedside ultrasound instead of waiting for the radiology tech to get the chest x-ray. But what’s the data?
Using pooled data from of 15 studies with 1553 CVC placements, Ablordeppey et al. found that ultrasound had a sensitivity of 86% and 98% specificity for detecting catheter malposition, with a positive likelihood ratio (LR) of 31.1 and a negative LR of 0.25. There was an almost 100% sensitivity and specificity for pneumothorax detection, and reduced confirmation time by 58 minutes.These findings are generally consistent across the board for the other studies out there.
1. Ablordeppey EA, Drewry AM, Beyer AB, et al. Diagnostic accuracy of central venous catheter confirmation by bedside ultrasound versus chest radiography in critically ill patients: a systematic review and meta-analysis. Crit Care Med. 2017; 45(4): 715-24.
2. Gekle R, Dubensky L, Haddad S, et al. Saline flush test: Can bedside sonography replace conventional radiography for confirmation of above-the-diaphragm central venous catheter placement? J Ultrasound Med. 2015;34(7):1295-9.
3. Weekes AJ, Johnson DA, Keller SM. Central vascular catheter placement evaluation using saline flush and bedside echocardiography. Acad Emerg Med. 2014; 21:65-72.
Category: Visual Diagnosis
Keywords: Pleural effusion; POCUS (PubMed Search)
A 50 years old male with a history of CHF, presenting to the ED with progressively worsening shortness of breath. POCUS was performed. The picture shows the left lower part of the chest. What is the diagnosis?
Answer: Pleural effusion
Eibenberger, K. L., Dock, W. I., Ammann, M. E., Dorffner, R., Hörmann, M. F., & Grabenwöger, F. (1994). Quantification of pleural effusions: sonography versus radiography. Radiology, 191(3), 681-684.
Atkinson, P., Milne, J., Loubani, O., & Verheul, G. (2012). The V-line: a sonographic aid for the confirmation of pleural fluid. Critical ultrasound journal, 4(1), 19.
Keywords: back pain, manipulation (PubMed Search)
We all wish there was a great treatment regimen for our patients with back pain. However, most studies have shown that it really does not matter what you do, as most patients will get better in 6 weeks.
A recent study published in JAMA looked at the role of spinal manipulation to improve pain and function in adults with low back pain. They looked at 26 randomized controlled trails and found that there was modest benefit for spinal manipulation and it was similar to using NSAIDs.
So spinal manipulation may or may not work for some patients. Something to consider along with physical therapy if patients are not getting relief with home remedies.
Keywords: Pediatrics, urinary tract infection, urine concentration (PubMed Search)
A recent study suggests that using a lower cut off value of white blood cells in dilute urine, may have a higher likelihood of detecting a urinary tract infection in children.
In dilute urine (specific gravity < 1.015), the optimal white blood cell cut off point was 3 WBC/hpf (Positive LR 9.9). With higher specific gravities, the optimal cut off was 6 WBC/hpf (Positive LR 10). Positive leukocyte esterase has a high likelihood ratio regardless of the urine concentration.
This was a retrospective study of 2700 infants < 3 months old who were evaluated for urinary tract infections (UTI). The UTI prevalence in this group was 7.8%. A UTI was defined as at least 50,000 colony forming units/mL from a catheterized specimen. Test characteristics looked at white blood cell and leukocyte esterase cut-offs, dichotomized into specific gravities: dilute (<1.015) and concentrated (>/=1.015).
Keywords: Glasgow Coma Scale, GCS, motor GCS, mGCS, Simplified Motor Scale, SMS (PubMed Search)
Bottom Line: The motor GCS and Simplified Motor Scale (SMS) have similar discrimination when compared with the total GCS, and may be easier to use.
Chou R, Totten AM, Carney N, et al. Predictive Utility of the Total Glasgow Coma Scale Versus the Motor Component of the Glasgow Coma Scale for Identification of Patients with Serious Traumatic Injuries. Ann Emerg Med. 2017 Jan 11. [Epub ahead of print].
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Category: Critical Care
Keywords: Hyperoxia, Mechanical Ventilation (PubMed Search)
The deleterious effects of hyperoxia are becoming more and more apparent. But obtaining a blood gas to ensure normoxia in a busy Emergency Department can be burdensome. And while the utilization of a non-invasive pulse oximeter seems ideal, the threshold that best limits the rate of hyperoxia is unclear.
Durlinger et al in a prospective observational study demonstrated that an oxygen saturation 95% or less effectively limited the number of patients with hyperoxia (PaO2 of greater than 100 mm Hg). Conversely when an SpO2 of 100% was maintained, 84% of the patients demonstrated a PaO2 of greater than 100 mm Hg.
Durlinger EM, Spoelstra-de man AM, Smit B, et al. Hyperoxia: At what level of SpO2 is a patient safe? A study in mechanically ventilated ICU patients. J Crit Care. 2017;
Keywords: EKG, athletes (PubMed Search)
Most of our knowledge of the athlete’s EKG is based on white athletes.
African/Afro-Caribbean athletes are more likely to have an abnormal EKG than white athletes in multiple studies.
Different selective criteria have been developed to minimize classification of benign normal patterns as abnormal.
The 2010 ESC criteria classified 40.4% of black athletes as abnormal versus the Refined criteria which resulted in 11.5% of EKGs classified as abnormal.
This reduction was aided by the recognition that isolated anterior TWI in asymptomatic black athletes is considered a benign finding.
Note this does NOT apply if the TWI extend to the lateral leads
For example, T-wave inversion (TWI) was present in 23% of African/Afro-Caribbean athletes vs. 3.7% of white athletes (usually in contiguous anterior leads).
Other changes included a higher prevalence of early repolarization, RV hypertrophy, and LA/RA enlargement.
1) Jacob et al., 2016. Ethnic and Gender Specific Differences Among Athletes Participating in ECG Screening.
2 )WIlson et al., 2012. Significance of deep T-wave inversions in asymptomatic athletes with normal cardiovascular examinations: practical solutions for managing the diagnostic conundrum.
3) Brown et al., 2017. THe Complex Phentype of the Athlete's Heart: Implications for the Preparticipation Screening.
Keywords: sodium bicarbonate, sodium acetate (PubMed Search)
FDA announced a shortage of sodium bicarbonate on 3/01/17. Sodium bicarbonate is frequently used in acid-base disorder as well as in poisoning (cardiac toxicity from Na-channel blockade, e.g. TCA & bupropion, and salicylate poisoning).
Acetate is a conjugate base of acetic acid where acetate anion forms acetyl CoA and enters Kreb cycle after IV administration. Final metabolic products of acetate are CO2 and H2O, which are in equilibrium with bicarbonate via carbonic anhydrase activity.
Administration of sodium acetate increases the strong ion difference by net increase in cations, as acetate is metabolize, and leads to alkalemia.
Adverse events from sodium acetate infusion have been associated with its use as dialysate buffer: myocardial depression, hypotension, hypopnea leading to hypoxemia and hyperpyrexia. However, such adverse events have not been reported in toxicologic application.
Sodium acetate can be administered safely in place of sodium bicarbonate if sodium bicarbonate is not available due to shortage.
Sodium acetate dose:
Neavyn MJ, Boyer EW, Bird SB, et al. Sodium acetate as a replacement for sodium bicarbonate in medical toxicology: a review. J Med Toxicol 2013;9:250-254.
Keywords: geriatric, trauma, imaging (PubMed Search)
· In the elderly, falling is the most common mechanism of injury
· Unavoidable Risk factors: age 85 or older, male, Caucasian, history of falls
· Other factors: alcohol consumption, polypharmacy
· Mechanisms of fall: slipping, tripping, stumbling
· Physical exam to include: gait, balance, proprioception, vision, strength and cognitive function testing
· Must consider neglect/abuse, affects 10% of seniors per year
· Evaluate for anticoagulant use due to increased risk of intracranial injury
· Use advanced imaging to identify occult hip fractures when clinically suspected and plain radiographs are negative
Abraham, MK, Cimino-Fiallos, NE. Falls in the Elderly: Causes, Injuries, and Management. Medscape February 1, 2017.
Category: Pharmacology & Therapeutics
Keywords: methadone, linezolid, serotonin syndrome, drug interaction (PubMed Search)
Linezolid is a weak, nonselective monoamine oxidase inhibitor (MAOI). A recent FDA Drug Safety Communication released in March 2016 noted reports of serotonin syndrome associated with certain opioids, particularly fentanyl and methadone. Development of serotonin syndrome after concomitant administration of linezolid with other serotonergic agents has been reported. Due to a potential risk of serotonin syndrome, a patient on chronic methadone should not be started on concomitant linezolid unless they will be monitored.
Follow me on Twitter @mEDPharmD
Keywords: pediatric, sepsis, infection, infants, children (PubMed Search)
Sepsis remains the most common cause of death in infants and children worldwide, with pneumonia being the most common cause of pediatric sepsis overall.
Strikingly, however, the mortality rate in pediatric sepsis is significant lower in children (10-20%) as compared to adults (35-50%).
The management of pediatric sepsis has been largely influenced by and extrapolated from studies performed in adults, in part due to difficulties performing clinical trial data in children with critical illness, including sepsis.
A major difference in management of children vs. adults with refractory septic shock with or without refractory hypoxemia from severe respiratory infection is the dramatic survival advantage of children when ECMO rescue therapy is used as compared to adults.
Bottom line: Consider ECMO for refractory pediatric septic shock with respiratory failure – in kids, survival is improved dramatically – consider it early!
For respiratory distress and hypoxia: Infants have a lower FRC and can desaturate very quickly!
Supplemental O2 should be delivered via face mask or nasal cannula or other devices such as high flow nasal cannula or nasopharyngeal CPAP, even if O2 saturation levels appear normal with peripheral monitoring devices
For improved circulation: utilize peripheral IO early
Peripheral IV or IO access can be used for fluid resuscitation, inotrope infusion, and antibiotic delivery when central access is not readily available or obtainable
Initial therapeutic resuscitative end points: hypotension and poor capillary refill may portend imminent cardiovascular collapse!
Antibiotics and source control: Early and aggressive source control is key, just as in adults!
Fluid resuscitation: Support the pump, and fill, but don’t overload the tank!
Inotropes and vasopressors: not just Levo for all!
Extracorporeal Membrane Oxygenation (ECMO)
Consider ECMO for refractory pediatric septic shock with respiratory failure – in kids, survival is improved dramatically – consider it early!
Randolph AG & McCulloh RJ. Pediatric sepsis: important considerations for diagnosing and managing severe infections in infants, children, and adolescents. Virulence. 2014: 1;5(1):179-89. doi: 10.4161/viru.27045.
Keywords: Pediatric poisoning, household , fatalities (PubMed Search)
Children less than 5 years of age account for the majority of poisoning exposures in the United States. As expected, accessible household items are the most frequently reported exposures and include cosmetics and personal care products, household cleaning substances, medications, and foreign bodies. Opioids are responsible for the highest incidence of hospitalizations followed by benzodiazepines, sulfonylureas, and cardiovascular drugs (beta & calcium channel blockers, and centrally acting antiadrenergic agents). Rise in buprenorphine use has led to significant increases in pediatric exposures. The most common sources of prescription medications were pills found on the ground, in a purse or bag, night stand, or pillbox. The 2015 American Association of Poison Centers Annual report lists 28 fatalities in children less than 5 year of age. Fatalities occurred from exposures to the following: narcotics (9), disc and button batteries (5), carbon monoxide (4), and other substances (10).
Highlighted AAPC cases include:
Poison prevention education of patients prescribed opioids or other highly toxic "one pill killers" who have young children in their household is recommended and could be potentially life saving.
2015 Annual Report of the American Association of Poison Centers' National Poison Data System: 33rd Annual Report. Mowrey JB, et al. Clinical Toxicology, 54:10.924-1109.
Emergency Hospitalizations for Unsupervised Prescription Medication Ingestions by Young Children, Lovegrove MC, et al. Pediatrics. 2014,134 (4) e1009-e1016 .
The Underrecognized Toll of Prescription Opioid Abuse on Young Children. Bailey JE, et al. Ann of Emerg Med. April 2009:53(4): 419-24. doi:10.1016/j.annemergmed.2008.07.015.Epub 2008 Sep 6.
Category: International EM
Keywords: Falls, elderly (PubMed Search)
· Falls are the second leading cause of accidental or unintentional injury deaths worldwide.
· Each year an estimated 424 000 individuals die from falls globally of which over 80% are in low- and middle-income countries.
· Adults older than 65 suffer the greatest number of fatal falls.
· 37.3 million falls that are severe enough to require medical attention, occur each year.
· Prevention strategies should emphasize education, training, creating safer environments, prioritizing fall-related research and establishing effective policies to reduce risk.
Category: Critical Care
DSI, Ketamine, and Apnea
Driver BE, Reardon RF. Apnea after low-dose ketamine sedation during attempted delayed sequence intubation. Ann Emerg Med 2017; 69:34-35.
Keywords: team doctor, sports medicine (PubMed Search)
Physicians are often called upon to serve as a team physician for a local high school in an official or unofficial capacity.
To aid in preparedness for sport-related emergencies, multiple national organizations have defined institutional best practices.
Knowledge of the following 3 best practice recommendations is important before taking on the role of “Doc covering the game”
1)The written Emergency Action Plan (EAP) – details the standard of emergency care at the particular venue.
2)The availability of life saving equipment: AED – where is it, charged and working?
3)Are the coaches trained in use of the AED and CPR. You can’t be everywhere and often multiple sporting events occur on campus simultaneously. It’s imperative that your first responder (coach or athletic trainer) can perform these tasks until you are able to respond
Please investigate these best practice recommendations before agreeing to serve as the physician for the local high school.
Keywords: rash, fingertip, bulla, nail disorder (PubMed Search)
2) Cohen R, Levy C, Cohen J, Corrard F, Deberdt P, Béchet S, Bonacorsi S, Bidet P. Diagnostic of group A streptococcal blistering
Keywords: adult clonidine overdose (PubMed Search)
Clinical signs and symptoms of clonidine overdose include CNS depression, bradycardia, and miosis. Other effects include early hypertension, followed by hypotension and respiratory depression, especially in children.
Although clonidine overdose in children is well described, frequency of clinical signs/symptoms in adults is not well characterized.
Recently, a retrospective study was performed in a hospital in Australia looking at clonidine overdose in adults.
Among isolated clonidine overdose, patients experienced:
Isbister GK et al. Adult clonidine overdose: prolonged bradycarida and central nervous system depression, but not severe toxicity. Clin Toxicol 2017;55:187-192.
Keywords: CT, MRI, tPA, peripartum, PRES (PubMed Search)
Majerisk JJ. Inherited and Uncommon Causes of Stroke. Continuum 2017;23(1):211–237.
Category: Critical Care
Keywords: lung protective ventilation, ARDS (PubMed Search)
While lung protective ventilatory strategies have long been accepted as vital to the management of patients undergoing mechanical ventilation, the translation of such practices to the Emergency Department is still limited and inconsistent.
Fuller et al employed a protocol ensuring lung-protective tidal volumes, appropriate setting of positive end-expiratory pressure, rapid weaning of FiO2, and elevating the head-of-bed. The authors found the number of patients who had lung protective strategies employed in the Emergency Department increased from 46.0% to 76.7%. This increase in protective strategies was associated with a 7.1% decrease in the rate of pulmonary complications (ARDS and VACs), 14.5% vs 7.4%, and a 14.3% decrease in in-hospital mortality, 34.1% vs 19.6%.
Fuller BM, Ferguson IT, Mohr NM, et al. Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial. Ann Emerg Med. 2017;
Keywords: Dilantin, Ataxia (PubMed Search)
Phenytoin is a first line anticonvulsant agent for most seizure disorders with the exception of absence and toxin-induced seizures. It has erratic gastrointestinal absorption with peak serum levels occurring anywhere from 3-12 hours following a single oral dose. 90% of circulating phenytoin is bound to albumin but only the unbound free fraction is active to cross cell membranes and exert pharmacological effect. Measured serum phenytoin levels reflect the total serum concentration of both the free and protein bound portions. Therapeutic range is between 10-20 mg/L. Free phenytoin levels are not often measured but are normally between 1-2 mg/L. Individuals with decreased protein binding (elderly, malnourished, hypoalbuminemia, uremia, and competing drugs) may have clincial toxicity despite a normal total phenytoin level. Toxicity consists of predominantly ocular and neurologic manifestations involving the vestibular and cerebellar systems:
|Plasma level, µg/mL||Clinical manifestations|
|10-20||Occasional mild nystagmus|
|30-40||Ataxia, slurred speech, extrapyramindal effects|
|>50||Coma, rare seizures|
Treatment of overdose is primarily supportive with serial drug level testing and neurologic exams. There is no evidence that gastrointestinal decontamination improves outcome. Routine cardiac monitoring is not necessary for overdose following oral ingestions. Cardiac toxicity is rarely seen and only with parenteral administration.
Phenytoin posisoning. Craig S. Neurocrit Care. 2005;3(2): 161-70.
Severe oral phenytoin overdose does not cause cardiovascular morbidity. Wyte CD, et al. Annals of EM. 1997; 20(5). 508-512.
Cardiac Monitoring after phenytoin overdose. Evers M, et al. Heart & Lung. 1997; 26:325-328.