Less than 1/2 of patients presenting to EDs and being diagnosed with concussion receive mild traumatic brain injury educational materials, and less than 1/2 of patients have seen a clinician for follow up by 3 months after injury.
In order to improve long term outcomes in patients with concusions please remember to provide the patient with approriate discharge instrucitons and strict instructions to follow up on their injury.
Full details of the article in JAMA can be found at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2681571
Keywords: Fever, infants, blood culture (PubMed Search)
The rate of occult bacteremia in infants 3 months to 24 months with a temperature higher than 40.5C was slightly higher when compared to those with a temperature higher than 39C.
363 infants (3 months to 24 months) with a fever > 40.5C who were well appearing were evaluated in this study. 4 were diagnosed with occult bacteremia (1.1%). 3 of these were caused by S. pneumoniae and 2 were fully immunized.
A larger sample size is needed to see if reconditions to include empiric blood cultures on this subgroup of patients is warrented.
After introduction of the pneumococcal conjugate vaccine, occult bacteremia dramatically decreased. Previous cost effective analysis showed that if the rate of occult bacteremia was less than 0.5%, then empiric testing should be eliminated, but if it is over 1.5%, then obtaining blood work is cost effective. In vaccinated patients, the occult bacteremia rates is less than 0.5%. These studies that showed this included patients with temperatures > 39C. This study looked at higher temperatures to see if there was a higher rate of occult bacteremia in this subgroup. In this ED, in all children with a temperature > 40.5C it was recommended that patients get a blood culture, WBC, ANC, CRP, UA, procalcitonin and PCR for pneumococcus and meningococcus regardless of immunization status. Further testing was at the discretion of the physician.
Gangoiti et al. Prevalence of Occult Bacteremia in Infants with Very High Fever without a source. Pediatr Infect Dis J. 2018 Feb. epub ahead of print.
Keywords: acute agitation, midazolam, antipsychotics, (PubMed Search)
Acutely agitated patients in the emegency room receive single or combination of benzodiazepine (lorazepam vs. midazolam) and antipsychotic (e.g. haloperidol) agents. Recently, use of ketamine has also been advocated to sedate agitated patients.
A recently published article compared IM administration several medications to treat acutely agitated patients in the ED. According to established protocol, each medication was administered in predetermined 3 week blocks:
N=737 with median age of 40 years, 72% men.
Midazolam resulted in greater proportion of patients with "adequate" sedation (altered mentatl status scale <1) compared to antipsychotics at 15 min post administration. Among antipsychotics, olanzapine resulted in greater proportion of patient with sedation.
Adverse effect were limited
Midazolam 5 mg IM achieve more effective sedation at 15 min in agitated ED patients than antipsychotics.
Klein LR et al. Intramuscular midazolam, olanzapine, ziprasidone or haloperidol for treating acute agitaion in the emergency department. Ann of Emerg Med 2018 June 6. pii: S0196-0644(18)30373-1. doi: 10.1016/j.annemergmed.2018.04.027. [Epub ahead of print]
Keywords: Syncope, neurological, neuroimaging, CT, MRI (PubMed Search)
Bottom Line: Consider obtaining neuroimaging in patients presenting with syncope only if clinical features suggest probable neurological syncope.
Syndesmotic sprain aka a “high ankle sprain”
Ankle injuries make up almost 30% of the injuries in professional football
High ankle injuries make up between 16 and 25% of these injuries in the NFL (lateral most common)
10% in general population
In comparison to lateral ankle sprains, high ankle sprains result in significantly more missed games, missed practices and required a longer duration of treatment
Anatomy: The syndesmosis comprises several ligaments and the interosseous membrane
Mechanism: External foot rotation with simultaneous rotation of the tibia and fibula.
Can lead to a Maisonneuve fracture
Injuries 4x more likely in game setting than practice
A positive proximal squeeze test significantly predicts missed games and practices compared to those without.
Conservative management for the stable high ankle injuries in professional football players. Knapik et al. Sports Health 2018
Keywords: augmentin, conjunctivitis, AOM, otitis media (PubMed Search)
Although conjuncitivitis outside of the neonatal period is commonly caused by viruses, there are times when antibiotics are warranted due to bacterial infections, such as conjuncitivits-otitis syndrome.
Bottom line: Every patient with conjunctivitis should have an examination of his/her TMs, as your management may change.
Teoh DL, Reynolds S. Diagnosis and management of pediatric conjunctivitis. Pediatric Emergency Care: 2003; 19(1), pp. 48-55.
Bodor FF, Marchant CD, Shurin PA, Barenkamp SJ. Bacterial etiology of conjunctivitis-otitis media syndrome. Pediatrics: 1985; 76(1), pp.26-28.
Bodor FF. Conjunctivitis-Otitis Syndrome. Pediatrics: 1982; 69(6), 695-698.
Keywords: fever, infection, physiology (PubMed Search)
Older patients are less likely than their younger counterparts to mount a fever in response to an infection. One explanation is that their basal temperature is lower. Some experts suggest redefining fever in older patients to match this decrease of 0.15C per decade. Therefore, your 80 year old patient would be considered “febrile” if their temperature is above 37.3C, rather than the traditional 38C.
Roghmann MC, Warner J, Mackowiak PA. The relationship between age and fever magnitude. Am J Med Sci. 2001;322(2):68-70
Category: Pharmacology & Therapeutics
Keywords: steroids, infection, leukocytosis (PubMed Search)
Steroids induce leukocytosis through the release of cells from bone marrow and the inhibition of neutrophil apoptosis. This effect typically occurs within the first two weeks of steroid treatment.
Leukocyte elevation is commonly used in the diagnosis of septic patients; however, this can be hard to discern in patients on concomitant steroid therapy.
A retrospective cohort study of adult patients presenting with fevers and a diagnosis of pneumonia, urinary tract infection, bacteremia, cellulitis, or COPD exacerbation was conducted to determine the maximal level of WBC within the first 24h of admission between patients on acute, chronic, or no steroid treatment.
Results: maximal WBC levels (p< 0.001)
· Acute steroid therapy: 15.4 ± 8.3 x 10 9/L
· Chronic steroid therapy: 14.9 ± 7.4 x 10 9/L
· No steroid therapy: 12.9 ± 6.4 x 10 9/L
An increase in WBC of 5 x 10 9/L can be found in acute and chronic steroid use when presenting with an acute infection and fever.
Frenkel A, Kachko E, Cohen K, Novak V, Maimon N. Estimations of a degree of steroid inducted leukocytosis in patients with acute infections. Am J Emerg Med. 2018;36(5):749-753.
Keywords: Heat, exertion, muscle (PubMed Search)
Exertional rhabdomyolysis (ER)
The warm weather is here and with it comes an increased risk of ER
Risks include the intensity, duration and types of exercises performed
One of the biggest risks is the exercise experience of the participants, both in those with little to no experience and in those experienced athletes less trained than their counterparts.
Multiple case reports find that intense novel exercises early in the preseason before getting acclimatized and “in shape” carry great risk to the participant. These can be summarized as “too much, too soon, too fast.”
Coaches need to be educated about this and be prepared to detect and effectively handle ER through an emergency action plan.
-Conditioning workouts need to be phased in rather than start at maximum intensity on day one.
Eccentric exercises appear worse than concentric exercises.
Has been seen in almost all sports, ranging from swimming to golf.
It’s not just preseason football!
High humidity and high temperature environments increase the likelihood of ER
Males are more vulnerable to ER than females
Increased risk with sickle cell trait and glycogen storage diseases
Multiple drugs may increase individual risk including alcohol, cocaine, amphetamines, MDMA and caffeine.
Implicated medicines include, salicylates, neuroleptics, quinine, corticosteroids, statins, theophylline, cyclic antidepressants and SSRIs
Football Team Rhabdomyolysis: The Pain Beats the Gain and the Coach Is to Blame Eichner, E., Randy, Current Sports Medicine Reports: May 2018
Keywords: myelopathy, myelitis, physical exam (PubMed Search)
Lhermitte’s phenomenon is as a sign of cervical spinal cord demyelination. It is considered positive if flexion of the neck causes a tingling sensation moving down the limbs or trunk, and may be reported as a symptom or elicited as a sign. This is due to stretching of the dorsal column sensory fibers, the commonest cause of which is multiple sclerosis. Other causes include other myelopathies, such as B12 deficiency, radiation and toxic (due to chemotherapy) or idiopathic myelitis. Its sensitivity is low at 16%, but its specificity for myelopathy is high at 97%.
Kempster PA, Rollinson RD. The Lhermitte phenomenon: variant forms and their significance. J Clin Neurosci 2008;15(4):379–81.
Khare S, Seth D. Lhermitte's Sign: The current status. Ann Indian Acad Neurol. 2015 Apr-Jun; 18(2): 154-156.
Category: Critical Care
Keywords: sepsis, septic shock, guidelines (PubMed Search)
Take Home Points:
For additional reading:
EMNerd, Dr. Rory Spiegel https://emcrit.org/emnerd/em-nerd-case-temporal-fallacy/
Surviving Sepsis Campaign http://www.survivingsepsis.org/Guidelines/Pages/default.aspx
Keywords: Button batteries, removal (PubMed Search)
There were 180 battery ingestions over a 5 year period at two tertiary care children’s hospital. The median age was 3.8 years (0.7 to 18 years). The most common symptoms were abdominal pain (17%), and nausea and vomiting (14%). X-rays detected the location in 94% of patients.
Based on these patients, a treatment algorithm was developed (See attached). Prospective validation is needed.
All patients with esophageal batteries had an intervention (foley catheter removal with post procedure esophagram, ridged esophagram or EGD).
The majority of patients with a gastric battery or small bowel battery were managed non operatively.
20 patients had a colonic battery and 7 had symptoms of abdominal pain or nausea or vomiting.
For batteries distal to the gastroesophageal junction, 16 patients had an intervention. 13 had an EGD with a 69% retrieval rate. 1 patient had a colonoscopy with successful retrieval. 2 patients had abdominal surgery with retrieval.
Rosenfled et al. Battery ingestions in children: Variations in care and development of a clinical algorithm. Journal of Pediatric Surgery. 2018. Epub ahead of print.
Keywords: Methylene Blue (PubMed Search)
Methylene Blue Used in the Treatment of Refractory Shock Resulting From Drug Poisoning. Fisher J, et al. Clin Toxicol 2914 Jan;52:63-65.
Calicum channel antagonist and beta blocker overdose: antidotes and adjunct therapies. Graudins A, et al. British Journal of Clin Pharm. 2016;81(3):453-461.
Category: Critical Care
Precedex (dexmedetomidine) is a selective alpha-2 adrenergic receptor agonist used as a sedative.
It is unique among sedatives typically used in the ICU in that it lacks GABA activity and lacks anticholinergic activity.
Previous studies have shown significant positive changes in sleep patterns in critically ill patients sedated with dexmedetomidine:
-improved sleep efficiency – decreased sleep fragmentation, decreased stage 1 sleep, increased stage 2 sleep
-improved distribution of sleep (with more than ¾ sleep occurring at night)
Given importance of sleep and preservation of day-night cycles/ circadian rhythms in prevention of delirium, a recent randomized controlled trial evaluated dexmedetomidine's effect on delirium.
100 delirium-free critically ill adults receiving sedatives were randomized to receive nocturnal (21:30-06:15) IV dexmedetomidine (titrated to RASS -1 or max 0.7 mcg/kg/hr) OR placebo until ICU discharge.
80% of patients in the dexmedetomidine group remained delirium-free vs 54% in the placebo group.
There was no difference in the incidence of hypotension, bradycardia, or both between groups.
Alexopolou, et al. Effects of Dexmedetomidine on Sleep Quality in Critically Ill Patients. Anesthesiology 2014; 121:801-7.
Skrobic, et al. Low Dose Nocturnal Dexmedetomidine Prevents ICU Delirium. Am J Respir Crit Care Med 2018; 197:9, 1147-56.
Keywords: Mild traumatic brain injury, concussion (PubMed Search)
Does mild traumatic brain injury increase risk of dementia?
Background: Most studies of moderate to severe TBI have found an association with increased risk of dementia and earlier onset of Alzheimer’s. There is growing concern that repeated TBIs, even if more mild, can lead to neurodegenerative conditions such as chronic traumatic encephalopathy (CTE). However, the link between mild TBI and dementia risk has not fully been elucidated, especially in the case of mild TBI without loss of consciousness (LOC).
Recent Data: A recent JAMA study evaluated the association between TBI severity, LOC, and dementia diagnosis in 350,000 veterans between 2001-2013. After adjusting for demographics as well as medical and psych comorbidities, veterans with even mild TBI without LOC had more than a 2-fold increase in risk of dementia diagnosis than those with no TBI. The risk increased only slightly if there was LOC (from a hazard ratio of 2.4 to 2.5). Risk was >3-fold for those with moderate-severe TBI.
Take home: TBI of any severity, even without LOC, appears to be associated with long term neurodegenerative consequences. Avoidance of TBI is of the utmost importance, and if TBI occurs, close neurocognitive follow up should occur.
Barnes DE, et al. Association of Mild Traumatic Brain Injury With and Without Loss of Consciousness With Dementia in US Military Veterans. JAMA Neurol. Online May 7, 2018.
Keywords: Factor Xa inhibitor, reversal agent, adexanet alfa, andexxa (PubMed Search)
On May 3, the FDA approved adexanet alfa, the reversal agent for factor Xa inhibitors - apixaban and rivaroxaban. It received both U.S. Orphan Drug and FDA Breakthrough Therapy designations.
Unlike indarucizumab (a monoclonal antibody fragment) to reverse dabigatran (direct thrombin inhibitor) associated bleeding, adexanet alfa is a recombinant modified human factor Xa decoy protein.
A phase 3 study showed that adexanet alfa decreased the anti-factor Xa activity of rivaroxaban by 92% from baseline and by 94% in apixaban treated participants.
ANNEXA-4 study involving participants with acute major bleeding (GI and intracranial) showed a significant decrease in the anti-factor Xa activity after the bolus dose of adexanet alfa and "effective" hemostasis was noted in 79% of the participants at 12 hours post infusion.
Andexanet alfa is expected to become available in June 2018.
Keywords: Intracerebral hemorrhage, ICH, hematoma expansion, prediction score, BAT score (PubMed Search)
Morotti A, Dowlatshahi D, Boulouis G, et al. Predicting intracerebral hemorrhage expansion with noncontrast computed tomography: The BAT score. Stroke 2018;49(5):1163-9.
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Keywords: pneumonia, infection, delirium, atypical (PubMed Search)
- Half of elderly patients presenting with pneumonia will manifest signs of delirium
- Tachypnea is the most reliable and earliest vital sign abnormality
- Classic symptoms are not often helpful at predicting severity of illness
- Symptoms are unreliable
- Cough (63-84%)
- Dyspnea (58-74%)
- Fever by history (53-60%)
- Fever at arrival (12-32%)
- Pleuritic chest pain (8-32%)
- Sputum (30-65%)
Caterino JM. Evaluation and management of geriatric infections in the emergency department. Emerg Med Clin N Am 2008;26:319-343.
Keywords: supination with flexion, hyperpronation (PubMed Search)
Nursemaid’s elbow is a common pediatric injury with peak incidence occurring between two and three years of age. It is a condition that typically arises from a sudden upward pull of the arm as an axial traction is placed on the forearm, and the radius is pulled through the annular ligament, resulting in subluxation of the radial head. Over the years, various maneuvers have been attempted, but the two most common are supination with flexion and hyperpronation. A 2017 Cochrane meta-analysis analyzed 8 trials specifically comparing supination with flexion versus hyperpronation. Data from those trials suggested that hyperpronation resulted in less failures at ?rst attempt than the supination-?exion, and although there was limited data, there was no obvious difference in adverse events or pain between the two techniques.
Bottom Line: There is likely a lower risk of failure with first attempt reduction with hyperpronation than with supination-flexion for nursemaid’s elbow.
1. Schutzman SA, Teach S. Upper-extremity impairment in young children. Ann Emerg Med. 1995;26:474-479.
2. Hart GM. Subluxation of the head of the radius in young children. J Am Med Assoc. 1959;169:1734-1736.
3. Vitello S, Dvorkin R, Sattler S, Levy D, Ung L. Epidemiology of Nursemaid’s Elbow. Western Journal of Emergency Medicine, Vol 15, Iss 4, Pp 554-557 (2014). 2014:554.
4. Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics. 1998;102:e10-e10.
5. Bexkens R, Washburn FJ, Eygendaal D, van den Bekerom M,P.J., Oh LS. Effectiveness of reduction maneuvers in the treatment of nursemaid's elbow: A systematic review and meta-analysis. Am J Emerg Med. 2016;34.
6. Krul M, van der Wouden J,C., van Suijlekom-Smit LW, Koes BW. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Syst Rev. 2009:CD007759.
7. Krul M, van der Wouden JC, van Suijlekom-Smit LW, Koes BW. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database Syst Rev. 2012.
8. Krul M. Manipulative interventions for reducing pulled elbow in young children. Cochrane Database of Systematic Reviews. 2017.
Keywords: Intralipid Emulsion (PubMed Search)
Despite initial excitement for the use of intravenous lipid emulsion (ILE) therapy as an antidote for serious poisonings due to lipohphilic drugs there remains an absence of evidence combined with an incomplete understanding of its efficacy, mechanisms of action, safety, and analytical interferences to recommend its use except in a few clinical scenarios.
The lipid emulsion workgroup performed a comprehensive analysis of four systematic reviews and based recommendations from consensus of expert panelists from the American Academy of Clinical Toxicology, the European Association of Poison Centres and Clinical Toxicologists, the American College of Medical Toxicology, the Asia Pacific Association of Medical Toxicology, the American Association of Poison Control Centers, and the Canadian Association of Poison Control Centers. Toxins evaluated had to have a minimum of three human cases reported in the literature.They concluded that ILE could be indicated for the following clinical situations:
The Bottom Line:
The use of Intravenous Lipid Emulsion in severe poisoning is recommended only for a few poisoning scenarios and was based on very low quality of evidence, and consideration of risks and benefits, adverse effects, laboratory interferences as well as related costs and resources.
Evidence-based recommendations on the use of intravenous lipid emulsion therapy in poisoning. Goseslin S. Hoegeberg L, Hoffman R, et al. Clinical Toxicology, 54:10, 899-923.
Intravenous Lipid Emulsion Therapy and VA-ECMO rescue therapy for Massive Venlafaxine and Clonazepam Overdose. Thomas A, Ovakim D, et al. J Clin Toxicol 2017 7: 368.