UMEM Educational Pearls

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!

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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:

•  20 month old with ingestion of 20 mm Lithuim disc battery with several previous ED visits for abdominal pain who developed an aorto-esophageal fistula 
• 13 month old with ingestion of unknown amount of salicylate pills 4 hours earlier with nausea and vomiting
• 2 year old with ingestion of 5 tablets of 30mg Oxycodone ER seen in ED and discharged 7 hours later. EMS called next morning found patient unresponsive and apneic
• 11 month old with ingestion of 1 unknown strength methadone pill found unresponsive and apneic at home

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.

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·       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.

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DSI, Ketamine, and Apnea

• In recent years, delayed sequence intubation (DSI) with ketamine has been used in select patients to maximize preoxygenation and dinitrogenation. 
• Importantly, DSI is not well studied. In the only prospective trial of DSI, patients received approximately 1.4 mg/kg of ketamine.
• Driver, et al. report the abrupt onset of apnea in a patient who received a much lower dose of ketamine (25 mg) for DSI.
• Take Home Point: If DSI is a part of your preoxygenation armamentarium, apnea can occur even at low doses of ketamine.  Stand at the patient's bedside and be ready to immediately intubate the patient.

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Question

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.

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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:

• GCS < 15: 55%
• GSS < 9: 5%
• Miosis: 25%
• Bradycardia (HR< 60): 68%
• Median HR: 48 (IQR: 40-62)
• Hypotension (SBP < 90 mmHg): 25%
• Median LOS: 21 hr (IQR: 11 – 27 hr)
• Intensive care: 23%
• No deaths

Bottom line:

1. The most common symtom of clonidicine overdose was bradycardia
2. Clonidine overdose results in non-life threatening but prolonged clinical effect in adult.

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• The incidence of stroke (both ischemic and hemorrhagic) in pregnant and peripartum women is three times age-matched controls. This increased risk is mostly in the 3rd trimester and up to 16 weeks postpartum. 

• Consider other causes of stroke:  posterior reversible encephalopathy syndrome (PRES), reversible cerebral vasoconstriction syndrome, cerebral venous sinus thrombosis and cardioembolic stroke from peripartum cardiomyopathy.

• CTs carry some risk due to the ionizing radiation, but with abdominal and pelvic shielding the exposure to the fetus is very low. MRIs do not carry that risk, but Gadolinium is absolutely contraindicated in pregnancy as it deposits in fetal tissue. 

• Pregnancy is a relative (not absolute) contraindication for tPA.

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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%.

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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:

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. 

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The World Health Organization (WHO) recently published their first ever list of antibiotic-resistant "priority pathogens".  These 12 families of bacterial pathogens have the potential to be a significant threat to human health.

These bacteria are divided in critical, high and medium priority pathogens. 

The critical pathogens requiring R & D for new antibiotics are:

1.     Acinetobacter baumannii, carbapenem-resistant

2.     Pseudomonas aeruginosa, carbapenem-resistant

3.     Enterobacteriaceae, carbapenem-resistant, ESBL-producing

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22yo college track athlete presents with 3 weeks of gradual onset groin and thigh pain, worse with running, better with rest.

Stress fractures are a common cause of groin pain in athletes, particularly in long distance runners

Fractures occur in the pubic rami and femoral neck 

Ask about a sudden change in training regimens

PE: check for tenderness to deep palpation over the pubic ramus. Ask athlete to stand and support full weight on affected leg or perform one legged hop on affected side. Pain out of proportion to physical examination findings. 

Imaging: XR usually negative. Bone scans can be positive as early as 4 to 8 days after symptom onset. MRI used to diagnose and rule out other causes of groin pain.

Treatment: Rest for 4 to 6 weeks. Consider making patient non weight bearing if walking causes pain especially with femoral neck fractures on the superior side. Inferior side neck fractures may benefit from prophylactic fixation.

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Preoxygenation in Critically Ill Patients

• Achieving adequate preoxygenation and denitrogenation prior to intubating critically ill patients can be challenging.
• Critically ill patients have physiologic alterations (i.e., derangements in oxygen consumption, anemia, reduced cardiac output, air space disease) that can markedly reduce safe apnea time.
• For patients with significant air space disease and shunt physiology, noninvasive ventilation (NIV) can decrease shunt fraction, increase functional residual capacity, improve PaO2, and lengthen safe apnea time.
• Importantly, NIV should be used for at least 3 minutes to achieve improvements in alveolar recruitment.
• It is also important to remove NIV just prior to larygnoscopy, as alveoli will begin to derecruit when NIV is removed.

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The Beers' Criteria lists 34 classes of medications that may be potentially inappropriate for geriatric patients due to a high risk of complications including increased risk for falls. When prescribing medications from the emergency department in geriatric patients, try to avoid these categories if other options are available.

http://www.americangeriatrics.org/files/documents/beers/BeersCriteriaPublicTranslation.pdf

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The addition of diazepam to naproxen for patients with acute, nontraumatic, nonradicular lower back pain did not improve pain or functional outcomes at 1 week or 3 months after ED discharge compared to placebo.

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Excited delirium syndrome (EDS) is a life-threatening condition caused by a variety of factors including drug intoxication.  EDS is defined as altered mental status, hyperadrenergic state, and combativeness or aggressiveness. It is characterized by tolerance to significant pain, tachypnea, diaphoresis, severe agitation, hyperthermia, non-compliance or poor awareness to direction from police or medical personnel, lack of fatigue, superhuman strength, and inappropriate clothing for the current environment. These patients are at high risk for sudden death. Toxins associated with this syndrome include:

• Lysergic acid diethylamide (LSD)
• Phencyclidine (PCP)
• 3,4-methylenedioxymethamphetamine (Ecstasy)
• Cocaine
• Methamphetamine
• Synthetic cathinones ("Bath salts") = Mephedrone, Methylone,  Methylenedioxypyrovalerone (MDPV), designer drugs similar to amphetamine.
• Synthetic cannbinoids

Ketamine at 4mg/kg dose can be given by intramuscular route and has been demonstrated to be safe and effective treatment for EDS.

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Emergency department crowding is an almost universal problem. Whether it is called "access block" (Austalia) or "boarding" (United States), it is seen everywhere.

The American College of Emergency Physicians (ACEP) states that "a “boarded patient” is defined as a patient who remains in the emergency department after the patient has been admitted to the facility, but has not been transferred to an inpatient unit."

It should be clear that the primary cause of overcrowding is boarding: the practice of holding patients in the emergency department after they have been admitted to the hospital, because no inpatient beds are available. This practice has been shown to have an adverse impact on patients, with longer delays causing greater morbidity and mortality.

ACEP has created resources to help address this issue, including an emergency medicine practice paper on high impact solutions. See: file:///Users/jhirshon/Downloads/EMPC_Crowding%20IP_092016%20(1).pdf

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A recently published study adds to the growing body of literature supporting the use of IV//IM ketamine as a first line agent for the control of the acutely agitated patient. In this observational cohort Riddell et al found patients given ketamine more frequently achieved adequate sedation at both 5 and 10 minutes compared to benzodiazepines, Haloperidol, given alone or in combination. This rapid sedation was achieved without an increase in the need for additional sedation or the rate of adverse events. 

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The Essex-Lopresti injury pattern is the lesser known of the triad of forearm injuries (Monteggia & Galeazzi).

It follows the “rule of the ring” aka the life saver candy rule: You can’t break a life saver in just one place.

These injury patterns are frequently missed because our eyes are drawn to the fracture and miss the associated dislocation.

The Essex-Lopresti fracture pattern involves a fracture of the radial head with concomitant dislocation of the distal radio-ulnar joint (DRUG)

               -With associated interosseous membrane disruption

Think of it as the Maisonneuve fracture of the forearm.

Mechanism: fall from height/high energy forearm trauma.

PE: Suspect if patient has significant tenderness at the DRUG with a radial head fx.

Patients have worse outcomes if injury is missed on initial presentation due to radial migration and instability.

Take home point: Remember the rule of the ring. Remember to exam the elbow with wrist injuries and the wrist with all elbow injuries

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