Keywords: Pediatrics, Bronchiolitis, Respiratory Decompensation, Risk factors (PubMed Search)
Bronchiolitis season will soon be upon us. Here are some risk factors for children under 2 y/o with bronchiolitis, who may be more likely to suffer respiratory decompensation:
1. Age under 9 months
2. Black race
3. Hypoxia documented in the ED
4. Persisent accessory muscle use.
Bottom Line: Consider providing respiratory support sooner than later in bronchiolitic infants with risk factors for decompensation. For HFNC, start at 1.5 - 2.0 L/kg/min, and titrate to work of breathing and 02 saturations.
Pathophysiology: Bronchiolitis is a disease process that leads to inflammation of lower airways, causing bronchiolar edema, epithelial hyperplasia, mucus plugging, and air trapping or atelectasis. Common viral causes include RSV, Human Metapneumovirus, Rhinovirus, Influenza, and Parainfluenza.
Clinical Course: For most strains, the disease course is often 5-7 days with the worst days being 3-5. The disease process can last longer, especially in neonates. The predominant presenting symptoms are often rhinorrhea, low grade fevers, and cough, but apnea can be the primary symptom in younger infants. As a result of increased work of breathing, PO feeding tolerance decreases and leads to dehydration.
Treatment: Primarily supportive care with suctioning, hydration, supplemental oxygen via standard NC, HFNC, and in severe cases BiPAP, CPAP or intubation. Trial of bronchodilator is often used, but there is no role for repeated bronchodilator use if no benefit is seen in pre and posttreatment respiratory effort. Hypertonic saline is not recommended for routine use in the ED. Corticosteroids have no role for routine use in viral bronchiolitis, either.
Keywords: Capsaicin, hunan hand, chili peppers (PubMed Search)
Hunan hand syndrome is a painful contact dermatitis that frequently presents in cooks and chili pepper workers after preparing or handling chili peppers. Contact with other body parts gives rise to the terms: "Hunan nose" ''Hunan eye",and "Chili Willie". Capsaicin, found in the fruit of plants from the genus Capsicum such as red chili peppers, jalapeños, and habaneros, is a hydrophobic, colorless, odorless compound that binds with pain receptors causing the sensation of intense heat or burning. The "heat" or pungency of a peppers is measured in Scoville heat units (SHU), the number of times a chili extract must be diluted with water to lose heat. Habanero peppers generate 30,000 SHU. Even at low concentrations capsaicin is a skin irritant. It is the primary ingredient in pepper spray used in law enforcement and in personal defense sprays.
Treatment consists of decontamination with water irrigation for opthalmic exposure and milk or antacids for dermal or gastrointestinal exposure. Burning can be recurrent and of of long duration depending on tissue penetration. Topical anesthetic especially for the eye and cool compresses for the skin can relieve pain. Parodoxically capsaicin is used as a topical analgesic medication for local pain relief from muscle pain, itching, and painful neuropathies (diabetic, postherpetic). Capsaicin initially causes neuronal excitation followed by a long-lasting refractory period due to depletion of substance P, during which neurons are no longer responsive to a large range of stimuli and thus are desensitized.
Category: Critical Care
Risk of Pneumocystis pneumonia (PCP) increases with degree of immunosuppression. If clinical suspicion exists (CD4 <200 with cough, pulmonary infiltrates, hypoxic respiratory failure), it is reasonable to initiate empiric therapy.
First line treatment is trimethoprim-sulfamethoxazole (TMP-SMX) orally or IV for 21 days. IV pentamidine has equivalent efficacy to IV TMP-SMX but greater toxicity and is generally reserved for patients with severe PCP who cannot tolerate or are unresponsive to TMP-SMX.
Importantly, adjunctive corticosteroids have been shown to significantly improve outcomes (mortality, need for ICU admission, need for mechanical ventilation) in HIV-infected patients with moderate to severe PCP (defined by pO2 <70 mmHg on Room Air).
· Ideally steroids should be started BEFORE (or at the same time as) Pneumocystis-specific treatment to prevent/mitigate the sharp deterioration in lung function that occurs in most patients after initiation of PCP treatment. This is thought to be secondary to the intense inflammatory response to lysis of Pneumocystis organisms, which can cause an ARDS-like picture.
· Recommended dosing schedule: 40mg prednisone twice daily for 5 days, then 40mg once daily for 5 days, followed by 20mg once daily for the remaining 11 days of treatment.
Bottom Line: In patients with moderate to severe PCP (pO2 <70 mmHg on RA), don’t forget to initiate adjunctive corticosteroids early (at the same time you initiate empiric therapy for PCP).
Wang RJ, Miller RF, Huang L. Approach to Fungal Infections in Human Immunodeficiency Virus–Infected Individuals. Clin Chest Med. 2017;38(3):465-477. doi:10.1016/j.ccm.2017.04.008.
Bozzette SA, Sattler FR, Chiu J, et al. A Controlled Trial of Early Adjunctive Treatment with Corticosteroids for Pneumocystis carinii Pneumonia in the Acquired Immunodeficiency Syndrome. N Engl J Med. 1990;323(21):1451-1457. doi:10.1056/NEJM199011223232104.
Montaner JS, Lawson LM, Levitt N, Belzberg A, Schechter MT, Ruedy J. Corticosteroids prevent early deterioration in patients with moderately severe Pneumocystis carinii pneumonia and the acquired immunodeficiency syndrome (AIDS). Ann Intern Med. 1990;113(1):14-20. http://www.ncbi.nlm.nih.gov/pubmed/2190515.
Category: International EM
Keywords: Influenza, southern hemisphere (PubMed Search)
The current number of influenza cases in the Southern Hemisphere is substantially higher than normal. For example, in Australia the number of influenza cases this year are twice the next highest year.
Have you gotten your flu shot yet?
Providing consistent, quality emergency care to the elderly is critically important. The Geriatric Emergency Department (GED) guidelines, developed collaboratively, provide a standardized set of guidelines to help improve care of the geriatric population in the emergency department.
In order to improve the standards for geriatric emergency care, representatives from the American College of Emergency Physicians, the American Geriatrics Society, Emergency Nurses Association, and the Society for Academic Emergency Medicine worked together to create the GED Guidelines. These guidelines create a template related to developing a geriatric focused emergency department, including specific recommendations related to staffing and administration, follow up and transition of care, education, quality improvement, equipment and supplies, as well as policies and procedures.
Keywords: stroke, tPA, thrombolytics, ICH, hemorrhage, adverse events (PubMed Search)
Keywords: ACL tear (PubMed Search)
Lever Sign/Lelli’s test
A new test for diagnosing ACL tears
Higher sensitivity (94 - 100%) than the Lachman test (highest sensitivity test to date)
With time and more study, this may become our new gold standard physical examination test
Very easy to learn and apply to bedside care
Can help with diagnosing partial tears
Area of manipulation is the femur and not the tibia (as in other tests)
Consider incorporating into your standard knee examination
Thank you to Ari Kestler for sending
Keywords: ARDS, oxygenation index, OI, PALICC, acute lung injury (PubMed Search)
Since the first description of acute respiratory distress syndrome (ARDS), various consensus conferences (including American-European Consensus Conference (AECC) and the Berlin Conference) have produced definitions focused on adult lung injury but have limitations when applied to children.
This prompted the organization of the Pediatric Acute Lung Injury Consensus Conference (PALICC), comprised of 27 experts, representing 21 academic institutions and eight countries. The goals of the conference were 1) to define pediatric ARDS (PARDS); 2) to offer recommendations regarding therapeutic support; and 3) to identify priorities for future research in PARDS.
Although there were several recommendations from the group, some notable ones, in contrast to the Berlin definition focused on adults, include: 1) use the Oxygenation Index (or, if an arterial blood gas is not available, the Oxygenation Severity Index) rather than the P/F ratio; 2) elimination of the requirement for “bilateral” pulmonary infiltrates (may be unilateral or bilateral) 3) elimination of specific age criteria for PARDS.
Tune in next month for pearls on management for children with PARDS...
Pediatric Acute Respiratory Distress Syndrome: Consensus Recommendations from the Pediatric Acute Lung Injury Consensus Conference. Pediatric Acute Lung Injury Consensus Conference Group. Pediatr Crit Care Med. 2015 Jun;16(5):428-39
Collaborators: Jouvet P, Thomas NJ, Wilson DF, Erickson S, Khemani R, Zimmerman J, Dahmer M, Flori H, Quasney M, Sapru A, Cheifetz IM, Rimensberger PC, Kneyber M, Tamburro RF, Curley MA, Nadkarni V, Valentine S, Emeriaud G, Newth C, Carroll CL, Essouri S, Dalton H, Macrae D, Lopez-Cruces Y, Quasney M, Santschi M, Watson RS, Bembea M.
Keywords: Hyperkalemia (PubMed Search)
Hyperkalemia is a potentially life threatening problem which can lead to cardiac dysrhythmias and death. Drug interactions inducing hyperkalemia are extremely common such as the combination of ACE inhibitors and spironolactone or ACE inhibitors and trimehoprim sulfamethoxazole. Hyperkalemia can also occur with a single agent and is a relatively common complication of therapy with trimethoprim sulfamethoxazole. The following drugs can cause hyperkalemia:
Drug induced hyperkalemia. Salem B. Badreddine A, et al. Drug Safety 2014 Sept;37(9) 677-92.
Beta-blockers, trimethoprim-sulfamethoxazole, and the risk of hyperkalemia requiring hospitalization in the elderly: a nested case-control study. Weir MA, Juurlink DN, et al. Clin J Am Soc Nephrol. 2010;5:1544-1551.
Category: International EM
Keywords: Octopus, tetrodotoxin (PubMed Search)
The blue-ringed octopus (genus Hapalochlaena) is normally found in the Great Barrier Reef and other coastal waters and tide pools around Australia and other Western Pacific islands. Though not an aggressive animal, when it does bite, such as stepped upon, it can inject tetrodotoxin along with a number of other toxic compounds.
Tetrodotoxin can cause paralysis, leading to respiratory failure and death, though the blockage of voltage-gated fast sodium channel conduction, blocking peripheral nerve conduction. Treatment is supportive, as the venom usually wears off within 4 to 10 hours.
Category: Critical Care
Post-Arrest Tidal Volume Setting
Beitler JR, et al. Favorable neurocognitive outcome with low tidal volume ventilation after cardiac arrest. Am J Respir Crit Care Med. 2017; 195:1196-1206.
Keywords: Sedation, URI, adverse events (PubMed Search)
Elective surgeries with general anesthesia are often cancelled when the child has an upper respiratory tract infection. What are the adverse events when procedural sedation is used when the child has an upper respiratory tract infection?
Recent and current URIs were associated with an increased frequency of airway adverse events (AAE). The frequency of AAEs increased from recent URIs, to current URIs with thin secretions to current URIs with thick secretions. Adverse events not related to the airway were less likely to have a statistically significant difference between the URI and non-URI groups
AAEs for children with no URI was 6.3%. Children with URI with thick/green secretions had AAEs in 22.2% of cases. Children with URIs did NOT have a significant increase in the risk of apnea or need for emergent airway intervention. The rates of AAEs, however, still remains low regardless of URI status.
Data was collected on over 83,000 patients retrospectively from a voluntary database, The Pediatric Sedation Research Consortium. Children with URIs (no fever) who underwent procedural sedation for things such as imaging or hematology/oncology procedures were included. Propofol, dexmedetomidine, ketamine and opiates were the most commonly used agents.
AAEs included wheezing, secretions requiring treatment, cough, stridor, desaturations, obstruction, snoring, laryngospasm, and apnea.
Mallory et al. Upper Respiratory Infections and Airway Adverse Events in Pediatric Procedural Sedation. Pediatrics. 2017; 140 (1): 1-10.
Keywords: SGLT2 inhibitors, diabetes (PubMed Search)
During the past several years, several new classes of diabetic medications were introduced for clinical use, including SGLT2 inhibitors (canagliflozin, dapagliflozin and empagliflozin).
SGLT2 inhibitors prevent reabsorption of glucose in the proximal convoluted tubules in the kidney and does not alter insulin release.
A recent retrospective study (n=88) of 13 poison center data from January 2013 to December 2016 showed
49 patients were evaluated in a health care facility (HCF) with 18 admissions. Referral to HCF was more common in pediatric patients. This was likely due to unfamiliarity with a new mediation and lack of toxicity data.
Other case reports have shown higher incidence of DKA with the therapeutic use of SGLT2 vs. other classes of DM medications.
Limit data is available regarding the toxicologic profile of SGLT2 inhibitors.
Based upon this small retrospective study, hypoglycemia may not occur and majority of the patient experience minimal symptoms.
Schaeffer SE et al. Retrospective review of SGLT2 inhibitor exposures reported to 13 poison center. Clin Toxicol (Phila).2017 Aug 16:1-5 PMID: 28812381
Burke KR et al. SGLT2 inhibitors: a systematic review of diabetic ketoacidosis and related risk factors in the primary literature. Pharmacothearpy. 2017;37:187-194
Keywords: seizure, status epilepticus, benzodiazepine, RAMPART, pediatric (PubMed Search)
IV vs. Non-IV Benzodiazepines for Cessation of Seizures
Follow me on Twitter @ EM_NCC
Category: Critical Care
Keywords: respiratory failure, pulmonary edema, airway obstruction (PubMed Search)
Negative-pressure pulmonary edema (NPPE) is a well-documented entity that occurs after a patient makes strong inspiratory effort against a blocked airway. The negative pressure causes hydrostatic edema that can be life-threatening if not recognized, but if treated quickly and appropriately, usually resolves after 24-48 hours. These patients may have any type of airway obstruction, whether due to edema secondary to infection or allergy, laryngospasm, or traumatic disruption of the airway, such as in attempted hangings.
1. Alleviate or bypass the airway obstruction.
· Usually via intubation; may require a surgical airway
· If obstruction in an intubated patient is due to biting on tube or dyssynchrony, add bite-block (if not already in place), sedation, and even paralysis if needed.
2. Provide positive pressure ventilation and oxygen supplementation.
3. Use low tidal volume ventilation.
4. In severe hypoxemia without shock, add a diuretic agent and consider additional measures such as proning and even ECMO if the hypoxemia is refractory to standard therapy.
Negative-pressure pulmonary edema (NPPE), also called post-obstructive pulmonary edema, can occur after any event in which a patient exerts strong inspiratory effort against an obstructed airway. This obstruction can be essentially due to any cause; in adults it is most well-documented secondary to post-extubation laryngospasm, in children the etiology is usually infectious, such as in epiglottitis. It has also been documented secondary to laryngeal edema, tumor, trauma, biting on an endotracheal tube, vent dyssynchrony, as well as disruptions to breathing mechanics during generalized seizures, among other causes.
It is noted that many of the documented cases involve patients who are relatively young and otherwise healthy, and thus capable of creating a strong negative intrathoracic pressure. The pathophysiology is thought to be related to hydrostatic mechanisms rather than a “leaky-capillary” permeability edema, and it usually resolves quickly if managed appropriately, within 24-48 hours. Diffuse alveolar hemorrhage, related to capillary rupture from the negative pressure, has been documented to occur in severe cases but is rare.
Consider the diagnosis in patients with an appropriate clinical picture or witnessed event leading to abrupt respiratory distress and/or failure. The diagnosis is even more strongly supported if they had absence of respiratory symptoms, or a clear chest x-ray prior to the event, with a chest x-ray demonstrating pulmonary edema afterwards.
Appropriate management of these patients includes:
1. Alleviation or bypass of the upper airway obstruction, which usually requires intubation.
· Depending on the etiology of obstruction (e.g. epiglottitis), endo/nasotracheal intubation may be difficult and a surgical airway may be necessary. Be prepared for this possibility.
· Ventilated patients who develop NPPE may require sedation to prevent biting on the ETT or to promote vent synchrony
2. Provide with positive-pressure ventilation to counteract the negative airway pressures, and oxygen supplementation to decrease pulmonary vascular resistance.
3. Lung-protective ventilation with low tidal volumes is generally accepted as the preferred ventilation strategy in these patients, extrapolated from data regarding its use in acute lung injury.
4. In cases of moderate to severe hypoxemia without the presence of shock, add a diuretic agent.
5. For refractory hypoxemia, consider early utilization of additional therapies, including neuromuscular blockade, proning, and ECMO.
Bhattacharya M, Kallet RJ, Ware LB, Matthay MA. Negative-pressure pulmonary edema. Chest. 2016;150(4):927-33.
Contou D, Voiriot G, Djibre et al. Clinical features of patients with diffuse alveolar hemorrhage due to negative-pressure pulmonary edema. Lung. 2017;195(4):477-487.
Keywords: Knee OA, injection (PubMed Search)
Hyaluronic acid (HA) is a high-molecular weight polysaccharide
A major component of synovial fluid and of cartilage
Major role of HA is as a lubricant, shock absorption, antinociceptive effect
Used in veterinary medicine for decades
Multiple brands exist with differences based on the molecular weight and how they are produced
Use supported by the Cochrane database (2007, 2014) for knee OA
Post injection strength gains are due to pain relief
May have a role for those who cannot receive steroid injections
Inject in similar manner to intra articular steroids
Caution in those with known allergy to poultry /eggs
Risks: Local reaction (likely from preservative), injection site pain, infection, bleeding.
Keywords: Radiographs, poisoning (PubMed Search)
Radiographs studies can be valuable in poisoning diagnosis, management, and prognosis. Radiographic imaging should be utilized for the following toxins:
Container toxins - Body packers
Sustained Released preparations
Plain adominal radiography: a powerful tool to prognosticate outcome in patients with zinc phosphide. Hassanian-Moghaddam H, Shahnazi M, et al. Clin Radiolol. 2014. Oct;69 (10);1062-5.
Systemic Plumbism following remote ballistic injury, Reinboldt M, Franics K, Emerg Radio. 2014 Aug:21 (4): 423-6.
Lead arthropathy: radiographic, CT, and MRI findings, Fernandes JL, Rocha AA, et al. Skeletal Radiol. 2007 Jul;36(7):647-57.
Intentional Intravenous Mercury injection. Yudelowitz G. S Afr Med J. 2017 Jan 30;107(2):112-114.
The role of radiology in diagnosis and management of drug mules: an update with new challenges and new diagnostic tools. Schulz B. Grossbach A, et al. Clin Radiol. 2014 Dec;69(12)
Keywords: fentanyl, first responder exposure (PubMed Search)
There have been reports of “intoxication” or adverse effects among first responders and law enforcement due to exposure to a “powder” suspected to be fentanyl or its analog.
This has led to a significant concern among first responders and law enforcement when investigating or handling “powder” at the scene of overdose or drug enforcement related raids. (http://www.foxnews.com/health/2017/08/15/police-department-gets-hazmat-like-protective-gear-for-overdose-calls.html)
American College of Medical Toxicology and American Association of Clinical Toxicology recently published a position statement to help clarify the potential health risk associated with exposure to fentanyl and its analogs.
Category: International EM
Keywords: Floods, earthquakes, hurricanes, natural disasters (PubMed Search)
With the recent destruction by Hurricane Harvey and the impending impact of Hurricane Irma, it is important to recognize the historical death toll from natural disasters. While the list can vary, here is a top ten list from the library of the National Oceanic and Atmospheric Administration:
Death Toll (Estimate)
1931 Yellow River flood
Yellow River, China
1887 Yellow River flood
Yellow River, China
1970 Bhola cyclone
Ganges Delta, East Pakistan
November 13, 1970
1938 Yellow River flood
Yellow River, China
June 9th, 1938
500,000 - 900,000
Shaanxi Province, China
January 23, 1556
2004 Indian Ocean earthquake/tsunami
December 26, 2004
1881 Haiphong Cyclone
1642 Kaifeng Flood
Kaifeng, Henan Province, China
July 28, 1976
* Official Government figure. Estimated death toll as high as 655,000.
Keywords: arrhythmia, syncope, fall (PubMed Search)
20% of unexplained falls in the elderly can be attributed to an arrhythmia.
Bhangu J, McMahon CG, Hall P, et al. Long-term cardiac monitoring in older adults with unexplained falls and syncope. Heart 2016;102:681-686.