[CORRECTION]: Versed dose is 2-2.5 mg total not mg/kg

Patients with severe agitation present a unique challenge to the emergency department. Acute delirium is often due to psychostimulants such as cocaine, amphetamines, PCP, or synthetic cannabinoids, alcohol, or psychiatric illness. These patients require urgent evaluation necesssitating the use of physical and chemical restraints, not only for their own safety but also the hospital staff's. Fingerstick glucose, pulse oximetry, and vital signs must be expeditiously obtained. Severely agitated combative patients who are physically restrained are at high risk for morbidity from asphyxiation, hypermetabolic consequences (acidosis, hyperthermia, rhabdomyolysis), and death can occur.

Ketamine is phencyclidine derivative that causes dissociative state between the cortical and limbic systems which prevents the higher centers from preceiving visual, auditory, or painful stimuli. Ketamine has a wide safety profile and has been used worldwide for many years with few complications. It possesses ideal characteristics for rapid sedation of agitated patients:

• Rapid onset of action 1-3 minutes
• Preservation of airway reflexes
• Lack of respiratory or cardiac depression or QT prolongation
• Short half-life of 30-40 minutes
• Safe in situations with minimal to no monitoring
• Dose: Intravenous =1.5-2 mg/kg Intramuscular = 5-6 mg/kg (maximum 400 mg)

Experience with Ketamine in patients with excited delirium has shown good initial control of agitation however, patients often require additional medications for deeper or longer duration of sedation. Benzodiazepines are recommmended as second line agents particularly intravenous or intramuscular Midazolam 2-2.5 mg /kg.

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As noted previously, injuries cause substantial morbidity and mortality globally.  How does it vary by age group?

The following table shows that unintentional injuries are the leading cause of death for individuals 1-44 years of age. Even when they are not the leading cause of death, injuries cause substantial mortality in all age groups.

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• Amiodarone and lidocaine are commonly used antiarrhythmics for ventricular fibrillation (VF) or pulseless ventricular tachycardia (VT). Their efficacy towards survival to hospital discharge and neurological outcome, however, has been questioned.
• A recently published study in the NEJM evaluated these drugs by performing a double-blind, randomized, placebo-control trial. The trial evaluated patients presenting with out of hospital cardiac arrest secondary to VF or pulseless VT that is refractory to one or more shock.
• The trial randomized 3,026 patients to receive amiodarone (974), lidocaine (993), or normal saline (i.e., placebo) (1,059); the primary outcome was survival to hospital discharge and the secondary outcome was favorable neurological outcome at hospital discharge. Several sub-group analyses were planned a priori.
• No statistically significant difference was found in hospital survival or neurologic outcomes between any of the groups. Patients who had a witnessed arrest and bystander CPR had higher rates of survival with either lidocaine or amiodarone compared to saline while there was no difference between the two.

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Guidelines recommend loading doses of vancomycin (15-20 mg/kg, up to 30 mg/kg in critically ill patients), but the risk of nephrotoxicity is unknown. A new retrospective cohort study aimed to compare nephrotoxicity in ED sepsis patients who received vancomycin at high doses (>20 mg/kg) versus lower doses (20 mg/kg).

What They Found

• 1,330 patients had three SCr values assessed for the primary outcome

• High-dose initial vancomycin was actually associated with a lower rate of nephrotoxicity (5.8% vs 11.1%)

• After adjusting for age, gender, and initial SCr, the risk of high dose vancomycin compared to low dose was decreased for the development of nephrotoxicity (RR=0.60; 95% CI: 0.44, 0.82)

Application to Clinical Practice

It appears initial loading doses of vancomcyin > 20 mg/kg do not cause increased risk of nephrotoxicity.

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Emergency medicine remains a relatively young and developing specialty in most parts of the world.  However, it is growing in popularity, especially in the U.S.  How competitive is it currently?

For the recent 2016 Match, there were 2476 applicants for 1895 categorical emergency medicine positions from 174 programs.

• Of the 1895 incoming residency positions, 1894 were filled within the Match!
• The vast majority (78.4%) were filled by senior medical students coming directly from U.S. medical schools.

Bottom Line: Emergency medicine remains a highly desired and competitive specialty in the U.S.

Congratulations to all the incoming interns for the 2016-2017 year!

What is cardio-renal syndrome CRS?

• Covers disorders where acute or long-term dysfunction of one organ can cause acute or long-term dysfunction of the other
• Worsening renal failure, diuretic resistance in heart failure, and worsening kidney function during heart failure are all characteristic of the disease process

There are 5 types

1. Acute CRS: abrupt worsening of heart function leading to kidney injury

2. Chronic CRS: chronic heart failure leads to progressive kidney disease

3. Acute renocardiac syndrome: abrupt kidney dysfunction leading to acute cardiac disorder

4. Chronic renocardiac syndrome: chronic kidney disease leading to decreased cardiac function

5. Systemic CRS: Systemic condition leading to both heart and kidney disease

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Metacarpal Fractures

* Localize fracture to head, neck or shaft (neck most common)

5th metacarpal most commonly fractured

* Note amount of angulation, shortening and the presence of malrotation

*Treatment is based on which metacarpal is fractured and the location of the fracture

*The amount of acceptable angulation varies by the digit involved

For example for index and long finger - acceptable angulation of the shaft is 10-20 degrees and neck is 10 to 15 degrees

Whereas for the 5th digit - acceptable angulation for the shaft is 40 degrees and neck is 50 degrees

Pearls

No degree of malrotation is acceptable (document the absence of this!)

Strongly suspect fight bite injury with abrasions/lacerations overlying metacarpal heads

Highly prone to infection given the proximity to the joint capsule

Consider lacerations over metacarpal fractures as open fractures (do not close/discuss management with hand surgery re timing of washout. Many prefer delayed fixation for suspected infections )

Document integrity of the extensor tendon (can be lacerated and retracted)

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Cerebral Venous Thrombosis

• Approximately 25% of patients with cerebral venous thrombosis (CVT) will experience neurologic deterioration.
• This is most commonly due to an increase in ICP that results in transtentorial herniation.
• While heparin remains the treatment of choice for CVT, consider the following alternative strategies in the acutely decompensating patient:
  • Endovascular thrombolysis
  • Mechanical thrombectomy
  • Decompressive hemicraniectomy

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A meta-analysis of 74 randomized trials with a total of 58,556 patients was recently published in the Lancet that looked at the effectiveness of NSAIDs in the treatment of osteoarthritis (OA) pain.

Briefly, their conclusion was that:

1. Acetaminophen is ineffective as a single-agent in the treatment of OA.
2. Diclofenac 150 mg/day had best evidence to support it as the most effective NSAID available presently with respective to its effectiveness in relieving pain and improving function.
3. They found no evidence that treatment effects varied over the duration of treatment ( no tolerance)
    

You can find the article here http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2816%2930002-2/abstract

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A previous pearl has looked at serum HCO3 as a predictor of DKA (see pearl from 8/21/15). The article by Gilhotra looks at using end tidal CO2 (ETCO2) to exclude DKA. 58 pediatric patients were enrolled with 15 being in DKA. No patient with ETCO2 > 30 mmHg had DKA. Six patients with ETCO2 < 30 mmHg did not have DKA. Other studies done in children have shown similar results.

An article recently published by Chebl and colleagues examined patients older than 17 years with hyperglycemia. In this study, 71 patients were included with 32 having DKA. A ETCO2 >35 excluded DKA in this group while a level <22 was 100% specific for DKA.

Bottom line: ETCO2 >35 mmHg is a quick bedside test that can aid in the evaluation of hyperglycemic patients.

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Cutaneous larva migrans (CLM) is an acquired dermatosis

• Seen in patients returning from the tropics
  • Often seen in patient with a history of sunbathing or in barefoot beachgoers
• Caused by the larvae of various nematode parasites of the hookworm family (Ancylostomatidae), with Ancylostoma braziliense the most frequently found in humans.

Clinical manifestations:

• Linear, serpentine erythematous lesions
• Intense pruritus
• Will often heal spontaneously over weeks or months without treatment

Treatment:

• Thiabendazole (applied topically)
  • Oral alternatives include other anti-parasitic medications such as albendazole, ivermectin
  • Oral thiabendazole as a single dose can be used, but is less effective than albendazole or ivermectin
• Consider antibiotics if there is secondary bacterial infections
• Freezing the leading edge has been previously used, but is considered ineffective and painful.

Bottom Line:

• Consider CLM the next time a patient complains of a linear, erythematous itchy rash after returning from their all-inclusive stay in a Caribbean resort

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Attachments

1603162221_clm.jpg (86 Kb)

There are multiple vasoactive infusions available for acute hypertensive emergencies, many having serious side effect profiles or therapeutic disadvantages.

Clevidipine (Cleviprex) is rapidly-titratable, lipid-soluable dihydropyridine calcium channel blocker which has become increasingly used in the ICU in recent years [1]:

• Onset of action 2-4 minutes
• Duration of action 5-15 minutes (half-life of 1 minute)
• Clevidipine is relatively inexpensive ($108/50mL bottle)
• Side effects include hypertriglyceridemia, hypotension and reflex tachycardia

ECLIPSE trial compares clevidipine, nicardipine, nitroglycerin and nitroprusside in cardiac surgery patients. .

Clevidipine was as effective as nicardipine at maintaining a pre-specified BP range, but superior when that BP range was narrowed (also studied in ESCAPE-1 and ESCAPE2 with similar results) [2-3]

TAKE-HOME: Clevidipine is an ultra short-acting, rapidly-titratable vasoactive with favorable cost, pharmacokinetics, and side-effect profile. Consider its use in hypertensive emergencies.

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Femoral neck fracture

• The most commonly missed hip fracture

We typically think of the presentation of the displaced fracture severe pain, writhing in the bed, unable to ambulate, limited ROM

* However, patients with nondisplaced fractures (15 20%) may walk with a limp

* Occurs primarily in the elderly & osteoporotic population after a fall directly onto the hip

* Look for a cortical step-off in the femoral neck (w/ foreshortening)

* A patient with a minimally displaced fracture may only complain of hip, knee, or groin pain and may be able to walk (albeit with a limp)

* Almost 9% of hip fractures are radiographically normal (Nondisplaced or impacted fractures)

* Fractures which were initially nondisplaced, may become displaced upon re-presentation

* Remember the limitations of plain x-ray in the evaluation of femoral neck fractures!

* Because of the significant complication of overlooking a femoral neck fracture, MRI has become the recommended imaging modality of choice for a patient with a high suspicion for a femoral neck fracture, despite normal plain radiographs of the hip

Acute cocaine toxicity can manifest with several cardiovascular issues such as tachycardia, dysrhythmia, hypertension, and coronary vasospasm. A new systematic review collated all of the available evidence for potential treatment options. Here is what the review found (there is also an 'other agents' section for medications with less published reports):

• Benzodiazepines and other GABA-active agents: Benzodiazepines may not always effectively mitigate tachycardia, hypertension, and vasospasm from cocaine toxicity.

• Calcium channel blockers: Calcium channel blockers may decrease hypertension and coronary vasospasm, but not necessarily tachycardia.

• Nitric oxide-mediated vasodilators: Nitroglycerin may lead to severe hypotension and reflex tachycardia.

• Alpha-adrenoceptor blocking drugs: Alpha-1 blockers may improve hypertension and vasospasm, but not tachycardia, although evidence is limited.

• Alpha-2-adrenoceptor agonists: There were two high-quality studies and one case report detailing the successful use of dexmedetomidine.

• Beta-blockers and alpha/beta-blockers: No adverse events were reported for use of combined alpha/beta-blockers such as labetalol and carvedilol, which were effective in attenuating both hypertension and tachycardia.

• Antipsychotics: Antipsychotics may improve agitation and psychosis, but with inconsistent reduction in tachycardia and hypertension and risk of extrapyramidal adverse effects.

• Sodium bicarbonate: Twelve case reports documented treatment of dysrhythmia with IV sodium bicarbonate, with seven reporting successful termination.

The authors note that "publication bias is a concern, and it is possible that successful treatment and/or adverse events have not been reported in some of the publications, and in general."

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Sunset Eye Sign

• The "sunset eye sign" can be seen in patients with increased intracranial pressure related to obstructive hydrocephalus or shunt malfunction.
• It describes an up-gaze paresis caused by compression of the dorsal midbrain.
• The lower portion of the pupil may be covered by the lower eyelid, appearing like a setting sun.

• The RUSH exam is a rapid way to identify the cause of shock using ultrasound. What's the RUSH exam? Click here
• The RUSH exam does not include an assessment of volume responsiveness (VR), but a new article by Blaivas, Aguiar, and Blanco suggests that it should be.
• VR has classically been assessed by determining the stroke volume before and after a passive leg raise or a fluid bolus. Click here for a video on how to calculate the stroke volume (skip to 21:30 in the video)
• The authors claim that VR can further be simplified by not measuring the left ventricular outflow tract (LVOT) and only comparing changes in the velocity-time integral (VTI). The assumption is that the LVOT is constant and doesn't change in most circumstances; a change of VTI that is greater than 15% suggests that the patient is VR
• Further validation is required to determine the degree of benefit to adding VTI to the RUSH exam, however measuring VTI is a skill that can be done with relatively little training and is clinically helpful.

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A new guideline for convulsive status epilepticus in adults AND children was recently published. [1] An insightful commentary was published alongside it (both are open access). [2] The proposed algorithm is below. Here are a few additional points to note:

• The guideline applies to convulsive status epilepticus.
• A new level of evidence rating of "U" is utilized. It means "data inadequate or insufficient; give current knowledge, treatment is unproven."
• It addresses 5 specific questions:
  • Which anticonvulsants are efficacious as initial and subsequent therapy?
  • What adverse events are associated with anticonvulsant therapy?
  • Which is the most effective benzodiazepine?
  • Is IV fosphenytoin more effective than IV phenytoin?
  • When does anticonvulsant efficacy drop significantly?
• IM midazolam is incorporated as one of the recommended 1st choices of treatment.
• One of the second phase therapy recommendations is levetiracetam 60 mg/kg! It is a level U recommendation. Be prepared for neurology to request this dose. There is no data in adults to support this high of a dose.

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Pure opioid agonists such as Morphine, Hydromorphone, and Fentanyl stimulate opioid receptors and are the most potent analgesics. Fentanyl and fentanyl analogues are up to 100 times more powerful than morphine and 30-50 times more powerful than heroin.

• Fentanyl abuse is causing significant problems worldwide. In the U.S., age-adjusted rate of death involving Fentanyl has increased 80% in 2014.
• Sources include production in illicit clandestine labs or diversion from legitimate pharmaceutical sales.
• 12 different analogues of Fentanyl have been identified in the U.S. drug traffic market.
• Commonly laced in heroin or cocaine or sold as fake Oxycodone or OxyContin tablets.

W-18 is a highly potent opioid agonist with a distinctive chemical structure which is not closely related to older established families of opioid drugs. While Fentanyl is approximately 100 times more powerful than Morphine, W-18 is about 100 times more powerful than Fentanyl.

• First discovered at the University of Alberta in 1982 in hopes of producing a non-addictive analgesic, 32 compound series named from W-1 to W-32, with W-18 being the most potent.
• Recently emerged on the streets of Canada when police in Calgary confiscated 110 green pills being sold as Fentanyl, known on the streets as "shady eighties" or "green beans pills" but chemical analysis revealed some pills containing W-18 instead.
• W-18 has never been used clinically as drug companies did not pick the patent, which lapsed by 1992 so little clinical experience.
• The effects of naloxone to reverse this synthetic opioid are unknown and higher doses are expected to to be required.
• Illicit drug manufacturers research pharmacological history in search of the more powerful, exotic, and new opioids to circumvent current legal regulations.

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While the flu season this year has been mild, it is still important to recognize which patients are at high risk for flu-related complications:

• Children < 5 years old
  • Especially children < 2 years old
• Adults > 65 years old
• Pregnant women
  • Including women up to 2 weeks post-partum
• Residents of long-term care facilities, such as nursing homes
• American Indians and Alaskan Natives
• Patients with certain medical conditions, including:
  • Respiratory diseases, such as asthma and COPD
  • Neurological and neurodevelopmental conditions
  • Heart disease, including CHF and CAD
  • Blood disorders (e.g. sickle cell disease)
  • Endocrine and metabolic disorders (e.g. diabetes)
  • Kidney or liver diseases
  • People <19 years old on long-term aspirin therapy
  • Morbid obesity (BMI > 40)
  • Immunocompromised, (e.g. chronic steroids, transplant patients, AIDS patients, chronic steroid use)

During the influenza season, when admitting a patient who 1) has respiratory symptoms and 2) is at high risk for influenza complications, consider testing them for influenza.

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