Category: Critical Care
Keywords: in hospital cardiac arrest, cardiac arrest (PubMed Search)
Posted: 4/26/2016 by Feras Khan, MD
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A recent survey looked at resuscitation practices that could help improve survival during in-hospital cardiac arrest
Category: Orthopedics
Keywords: Sudden cardiac death, physical activity (PubMed Search)
Posted: 4/23/2016 by Brian Corwell, MD
(Updated: 11/23/2024)
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Exercise and the heart
Exercise increases the risk of sudden cardiac death (SCD) acutely.
Exercise decreases the risk of SCD in the long term.
Regular physical activity (even as little as 15 mins/day) reduces the risk of cardiovascular disease (CVD).
Up to 15% of MIs occur during or soon after vigorous physical exercise. This is typically in sedentary men with coronary risk factors.
In a 1993 study, in the first hour after heavy exertion, risk of heart attack rose more than 100-fold from baseline for habitually inactive persons. However, for frequent exercisers, this risk rose less than three-fold. Think of snow shoveling after a winter storm.
Both the Physicians’ Health Study and the Nurses’ Health Study show that the risk of SCD during exertion is reduced by habitual exercise.
If you are physically active, stay active. If you are not active, you should be because exercise has innumerable personal benefits. However, it is important to start gradually Some individuals at higher risk need to start under the guidance of a physician.
Category: International EM
Keywords: Research, ethics, informed consent (PubMed Search)
Posted: 4/21/2016 by Jon Mark Hirshon, PhD, MPH, MD
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The terms and concepts of “waiver of informed consent’ versus “exception from informed consent” are often confused. Within the U.S., these concepts are not the same.
Bottom line:
Waiver of Informed Consent ≠ EFIC
These are the rules and regulations for the U.S. The regulations for emergency research in other countries may or may not be similar to these.
45 CFR 46.116(d)
21 CFR 50.24 and 45 CFR 46.101
Category: Critical Care
Posted: 4/19/2016 by Mike Winters, MBA, MD
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Can NIV be Used in ARDS?
Demoule A, et al. Can we prevent intubation in patients with ARDS? Intensive Care Med 2016; 42:768-771.
Category: Pediatrics
Keywords: Intracranial hemorrhage, ultrasound, non accidental trauma (PubMed Search)
Posted: 4/15/2016 by Jenny Guyther, MD
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Typically, if an infant or young child presents to the ED with concern for intracranial hemorrhage (ICH), CT is performed as a rapid diagnostic tool. Now that clinicians are more aware of the radiation associated with head CT, the possible use of ultrasound was studied. Ultrasound is commonly used in the neonatal population for detecting ICH. A study by Elkhunovich et al looked at children younger than 2 years who had cranial ultrasounds preformed. Over a 5 year period, 283 ultrasounds were done on patients between 0 to 485 days old (median 33 days). There were 39 bleeds detected. Ultrasound specificity and sensitivity was calculated by comparing the results with CT, MRI and/or clinical outcome. For significant bleeds, the sensitivity for ultrasound was 81%. The specificity for detecting ICH was 97%.
Only 2 patients in the study were older than 1 year. The proper windows are easiest to visualize in children younger than 6 months.
Bottom Line: The sensitivity of cranial ultrasound is inadequate to justify its use as a screening tool for detection of ICH in an infant with acute trauma, but it could be considered in situations when obtaining advanced imaging is not an option because of availability or patient condition.
Elkhunovich M, Sirody J, McCormick T, Goodarzian F and Claudius I. The Utility of Cranial Ultrasound for Detection of Intracranial Hemorrhage in Infants. Ped Emerg Care 2016 [epub ahead of print].
Category: Toxicology
Keywords: Extracorporeal Membrane Oxygenation, ECMO, toxicology, poison (PubMed Search)
Posted: 4/13/2016 by Bryan Hayes, PharmD
(Updated: 4/14/2016)
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The American College of Medical Toxicology's ToxIC Registry is a self-reporting database completed by medical toxicologists across 69 insitutions in the US.
Application to Clinical Practice
In settings where ECMO is available, it may be a potential treatment option in severely poisoned patients. From the limited data, ECMO was generally administered prior to cardiovascular failure and might be of benefit particularly during the time the drug is being metabolized.
Table from the Case Series
Wang GS, et al. Extracorporeal Membrane Oxygenation (ECMO) for Severe Toxicological Exposures: Review of the Toxicology Investigators Consortium (ToxIC). J Med Toxicol 2016;12(1):95-9. [PMID 26013746]
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Category: Neurology
Keywords: dizzy, dizzinesss, acute vestibular syndrome, triggered episodic vestibular syndrome, spontaneous episodic vestibular syndrome, HINTS, Dix-Hallpike (PubMed Search)
Posted: 4/13/2016 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD
What Do You Mean By Dizzy?
Table 1 shows common benign and serious causes of these vestibular syndromes.
Utilizing the HINTS battery or the Dix-Hallpike maneuver, a “safe to go” algorithm for acute vestibular syndrome and triggered episodic vestibular syndrome is outlined in Figure 2.
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Category: Critical Care
Keywords: seizure, status epilepticus, pregnancy (PubMed Search)
Posted: 4/13/2016 by Daniel Haase, MD
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Disclaimer: Talking about seizures/status that is NOT due to eclampsia
TAKE HOME: While no AEDs are completely safe in pregnancy, treatment and stabilization of maternal status epilepticus is paramount for fetal health. Involve neurology/epileptology and OB/maternal-fetal medicine.
1. Hern ndez-D az S, et al; North American AED Pregnancy Registry; North American AED Pregnancy Registry. Comparative safety of antiepileptic drugs during pregnancy. Neurology. 2012 May 22;78(21):1692-9.
2. McElhatton PR. The effects of benzodiazepine use during pregnancy and lactation. Reprod Toxicol. 1994 Nov-Dec;8(6):461-75.
3. Lexicomp online accessed via uptodate.com.
Category: Orthopedics
Posted: 4/10/2016 by Brian Corwell, MD
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Orthopedic documentation
1) Document location with specificity and laterality.
2) Document the location with as much specificity as possible
-Name of specific bone and specific site on bone (Shaft, head, neck, distal, proximal, styloid)
3) Document fractures as open/closed, displaced vs. non-displaced, routine or delayed healing,
-Orientation of fractures, such as transverse, oblique, spiral
- Document intra-articular or extra-articular involvement
4) For a particular injury, a complete note will include mention of the following
The joint above (e.g. for shoulder injuries this would be the neck, for hip injuries - the back)
The joint below
Motor (e.g. for arm injuries document the distal median, radial and ulnar motor innervation)
Sensory
Vascular
Skin (for all fractures document intact overlying skin esp. when covering with a splint)
Compartments (a simple mention of compartments are grossly soft/not tense will suffice)
*Especially relevant for forearm and tib/fib injuries
Category: Toxicology
Keywords: Ketamine, Benzodiazepines (PubMed Search)
Posted: 4/7/2016 by Kathy Prybys, MD
(Updated: 4/8/2016)
Click here to contact Kathy Prybys, MD
[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:
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.
Scheppke KA, Braghiroli J, Shalaby M, Chait R. Prehospital Use of IM Ketamine for Sedation of Violent and Agitated Patients. Western Journal of Emergency Medicine. 2014;15(7):736-741.
Isbister GK, Calver LA, et al. Ketamineas RescueTreatment for Difficult-to-Sedate Severe Acute Behavioral Disturbance in the Emergency Department. Ann Emerg Med 2016 Feb 10 [Epub ahead of print].
Category: International EM
Keywords: Mortality, injuries (PubMed Search)
Posted: 4/6/2016 by Jon Mark Hirshon, PhD, MPH, MD
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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.
http://www.cdc.gov/injury/images/lc-charts/leading_causes_of_death_age_group_2014_1050w760h.gif
Category: Critical Care
Posted: 4/5/2016 by Haney Mallemat, MD
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Category: Pharmacology & Therapeutics
Keywords: vancomycin, loading dose, nephrotoxicity (PubMed Search)
Posted: 3/24/2016 by Bryan Hayes, PharmD
(Updated: 4/2/2016)
Click here to contact Bryan Hayes, PharmD
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.
Rosini JM, et al. High single-dose vancomycin loading is not associated with increased nephrotoxicity in emergency department sepsis patients. Acad Emerg Med. 2016 Feb 6. Epub ahead of print. [PMID 26850378]
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Category: International EM
Keywords: Match, training, emergency medicine, residency (PubMed Search)
Posted: 3/26/2016 by Jon Mark Hirshon, PhD, MPH, MD
(Updated: 4/6/2016)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD
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.
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!
Category: Critical Care
Keywords: cardiorenal syndrome, heart failure, kidney failure (PubMed Search)
Posted: 3/29/2016 by Feras Khan, MD
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What is cardio-renal syndrome CRS?
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
Category: Orthopedics
Keywords: Metacarpal Fractures (PubMed Search)
Posted: 3/26/2016 by Brian Corwell, MD
Click here to contact Brian Corwell, MD
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)
Category: Neurology
Keywords: geriatrics, seizures, mimics, TIA, syncope (PubMed Search)
Posted: 3/23/2016 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS
Carlson C, Anderson CT. Special Issues in Epilepsy: The Elderly, the Immunocompromised, and Bone Health. Continuum 2016;22(1):246 261
Category: Critical Care
Posted: 3/22/2016 by Mike Winters, MBA, MD
Click here to contact Mike Winters, MBA, MD
Cerebral Venous Thrombosis
Fam D, Saposnik G. Critical care management of cerebral venous thrombosis. Curr Opin Crit Care 2016; 22:113-9.
Category: Orthopedics
Keywords: osteoarthritis, nsaids (PubMed Search)
Posted: 3/20/2016 by Michael Bond, MD
(Updated: 11/23/2024)
Click here to contact Michael Bond, MD
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:
You can find the article here http://www.thelancet.com/journals/lancet/article/PIIS0140-6736%2816%2930002-2/abstract
Category: Pediatrics
Keywords: End tidal capnography, diabetic ketoacidosis (PubMed Search)
Posted: 3/19/2016 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD
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.
Gilhotra Y and Porter P. Predicting diabetic ketoacidosis in children by measuring end-tidal CO2 by non-invasive nasal capnography. J Paediatr Child Health 2007; 43 (10): 677-80.
Chebl BR, Madden B, Belsky J, Harmouche E, Yessayan L. Diagnostic value of end tidal capnography in patients with hyperglycemia in the emergency department. BCM Emerg Med 2016: 16 (1).