UMEM Educational Pearls

Shock Index

• The shock index (SI) is calculated as the ratio of heart rate to systolic blood pressure and is often used in the assessment of critically ill patients.
• A SI > 0.8 has been shown to be an independent predictor of post-intubation hypotension during emergency airway management.
• Kristensen and colleagues performed a retrospective review in a single-center in Denmark to evaluate the ability of SI to predict 30-day mortality.
• In over 110,000 patients, they found a weaker association of SI with 30-day mortality in patients > 65 years of age, those taking a beta-blocker or calcium channel blocker, or those with a history of hypertension.
• Notwithstanding, a SI > 1 was a significant predictor of mortality across all patient populations and should be considered a warning of serious illness.

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Recommended follow-up for common orthopedic injuries

Lead is a ubiquitous metal in the environment partly due to decades of using leaded gasoline (organic lead) and lead-based paint (inorganic lead). Outside of occupational exposure, children are disproportionately affected from environmental lead exposure.

Common route of exposure are:

1. Ingestion (common in children): soil, water, lead-based paint chips, toys, certain folk remedies.
   • Absorption: adult: 3 – 10% vs. children: 40 – 50%
2. Inhalation (mostly occupational exposure): lead dust
   • Absorption: 30 – 40%
3. Dermal (minor): cosmetic products
   • Absorption: < 1%

Majority of the absorbed lead are stored in bone (years) > soft tissue (months) > blood (30-40 days) (half-life). Thus blood lead level does not accurately reflect the true body lead burden.

Incidence of elevated blood lead level (EBLL > 5 microgram/dL) in children increased from 2.9 to 4.9% in Flint, MI before and after water source change. In the area with the highest water lead level, the incidence increased by 6.6%.

Clinical manifestation in children

Evaluation for lead poisoning

1. Blood lead level (BLL)
2. CBC: hypochromic microcytic anemia, basophilic stippling
3. Imaging: abdominal XR – check for foreign bodies in GI tract; long-bone XR – lead lines

Management of children with EBLL

1. Removal from exposure
2. Environmental investigation/intervention (BLL: 15 - 44 ug/dL)
3. Chelation
   • Asymptomatic (BLL: 45 – 69 ug/dL): Succimer (PO)
   • Symptomatic (BLL: > 70 ug/dL): Dimercaprol (IM) and CaNa₂EDTA (IV)

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Zika virus is a mosquito-borne flavivirus. 

• The flavivirus genus includes multiple other human viral infections, including yellow fever, West Nile, dengue and tick-borne encephalitis.
• The primary vector for Zika virus is Aedes aegypti, though Aedes albopictus can also transmit it.

While outbreaks have been previously reported in Africa, Asia and the islands of the Pacific, it was first reported in the Western Hemisphere in May 2015. 

• Per the CDC, as of January 15, 2016, local transmission had been identified in at least 14 countries or territories in the Americas. 
• There has been no local transmission (yet) in the Continental US.

Clinical Disease:

• One in five infected become symptomatic
• Clinical illness is usually mild and lasts for several days or a week
  • Severe disease is uncommon, though Guillain-Barre syndrome has been reported in patients following suspected Zika infection
  • Fatalities are rare
  • Of note: congenital malformations have been seen in pregnant women infected with Zika
• Characteristic clinical findings can include:
  • acute onset of fever,
  • maculopapular rash,
  • arthralgia,
  • conjunctivitis

Diagnosis and Treatment

• Consider the diagnosis in symptomatic travels returning from affected areas
• RT-PCR can be used on serum specimens from the first week of illness
• There is no current commercial test available
• Treatment is symptomatic and supportive
  • No specific antiviral therapy

Prevention

• Avoid mosquito bites
  • Wear long sleeves and pants
  • Use insect repellents when outdoors (such as DEET)
  • Delay travel to known affected areas if you are pregnant

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What classifies "submassive PE"?

• Echocardiographic signs of RV strain (RV dilation/systolic dyfunction, decreased TAPSE)
• Hemodynamic stability (SBP >90)
• Patients may or may not have abnormal cardiac biomarkers (elevated troponin, BNP)

Submassive PE has early benefit from systemic thrombolysis at the cost of increased bleeding [1].

Ultrasound-accelerated, catheter-directed thrombolysis (USAT) [the EKOS catheters] has been shown to be safe, with low mortality and bleeding risk, as well as immediately improved RV dilation and clot burden [2-4]. USAT may improve pulmonary hypertension [4].

USAT is superior to heparin/anti-coagulation alone for submassive PE at reversing RV dilation at 24 hours without increased bleeding risk [5].

Long-term studies evaluating chronic thromboembolic pulmonary hypertension (CTEPH) need to be done, comparing USAT with systemic thrombolysis and surgical thombectomy.

Take-home: In patients with submassive PE, USAT should be considered over systemic thombolysis or anti-coagulation alone.

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Question

23 year-old female presents complaining of progressive right lower quadrant pain after doing "vigorous" exercise. CT abdomen/pelvis below. What’s the diagnosis? (Hint: it’s not appendicitis)

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The Salter Harris Classification System is used in pediatric epiphyseal fractures. The higher the type of fracture the greater the risk of complications and growth disturbance.

Some common exam facts about Salter Harris Fractures are:

• The type II fracture is the most common.
• The small metaphyseal fragment in Salter Harris type II and IV fractures is called the Thurston Holland Sign.
• Type III and IV fractures often require open reduction and internal fixation due to the fracture extending into the joint.
• Type V fractures may appear normal, but the epiphyseal plate is crushed and the blood supply is interrupted.

The Classification system as listed by Type:

• Type I: A fracture through the physeal growth plate. Typically can not be seen on x-ray unless they growth plate is widened or displaced..
• Type II: A fracture through the physeal growth plate and metaphysis.
• Type III: A fracture through the physeal growth plate and epiphysis.
• Type IV: A fracture through the epiphysis, physeal growth plate and metaphysis.
• Type V: A crush injury of the physeal growth plate.

For Maite, a helpful mnemonic is SALTR , Slipped (Type I), Above (Type II), Lower (Type III), Through (Type IV), and Ruined or Rammed (Type V)

A image of the fractures can be found on FP Notebook at http://www.fpnotebook.com/ortho/fracture/ephyslfrctr.htm

ED study of 60 pediatric patients for procedural sedation

• Fentanyl 1 mcg/kg was followed by 0.1 to 0.2 mg/kg of etomidate IV.
• One dose of 0.2 mg/kg IV etomidate was adequate for 39/60 patients
• 16.4% had respiratory depression
• Desaturation occured in 23 patients
• No patient required positive pressure ventilation
• Average recovery in 21 minutes

Bottom line: Etomidate can achieve effective sedation in children for a short procedure. Although respiratory effects were noted, none of them required assisted ventilation.

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The three-bag IV acetylcysteine regimen for acetaminophen overdose is complicated and can result in medication/administration errors. [1] Two recent studies have attempted simplifying the regimen using a two-bag approach and evaluated its effect on adverse effects. [2, 3]

Study 1 [2]

Prospective comparison of cases using a 20 h, two-bag regimen (200 mg/kg over 4 h followed by 100 mg/kg over 16 h) to an historical cohort treated with the 21 h three-bag IV regimen (150 mg/kg over 1 h, 50 mg/kg over 4 h and 100 mg/kg over 16 h).

The two-bag 20 h acetylcysteine regimen was well tolerated and resulted in significantly fewer and milder non-allergic anaphylactic reactions than the standard three-bag regimen.

Study 2 [3]

Prospective observational study of a modified 2-phase acetylcysteine protocol. The first infusion was 200 mg/kg over 4-9 h. The second infusion was 100 mg/kg over 16 h. Pre-defined outcomes were frequency of adverse reactions (systemic hypersensitivity reactions or gastrointestinal); proportion with ALT > 1000 U/L or abnormal ALT.

The 2-phase acetylcysteine infusion protocol resulted in fewer reactions in patients with toxic paracetamol concentrations.

Final word: Two-bag regimens seem to offer advantages compared to the traditional three-bag regimen with regard to reduced adverse drug reactions. Look for more data, particularly on effectiveness, and a potential transition to a two-bag approach in the future.

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• A recent systematic review looked at the prevalence of psychiatric disorders such as anxiety and depressive disorders in patients with traumatic brain injury (TBI).
• They found a substantial number of patients had a history of anxiety disorders (19%) or depressive disorders (13%) prior to their TBI.
• In the first year after TBI, pooled prevalence of anxiety and depressive disorders increased to 21% and 17%.
• Prevalence continued to increase over time, with longterm prevalence of anxiety and depressive disorders of 36% and 43%.
• Females, those without employment, and those with a history of psychiatric disorders or substance abuse prior to TBI were at higher risk for anxiety or depressive disorders following TBI.

Bottom Line: 

• Early recognition and treatment of psychiatric disorders in patients after TBI may improve their outcome, psychosocial functioning and health-related quality of life. 
• Thus we should consider providing appropriate discharge instructions that include psychiatric resources for patients after TBI.

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There are so many variables to monitor during CPR; speed and depth of compressions, rhythm analysis, etc. But how much attention do you give to the ventilations administered?

The right ventricle (RV) fills secondary to the negative pressure created during spontaneously breathing. However, during CPR we administer positive pressure ventilation (PPV), which increase intra-thoracic pressure thus reducing venous return to the RV, decreasing cardiac output, and coronary filling. PPV also increases intracranial pressure by reducing venous return from the brain.

So our goal for ventilations during cardiac arrest should be to minimize the intra-thoracic pressure (ITP); we can do this by remembering to ventilate "low (tidal volumes) and slow (respiratory rates)"

• Low: Use only one-hand while bagging, this will give the patient 500-600cc per breath. Using two-hands provides ~900-1,000cc per squeeze (more than we normally ventilate patients who have a pulse).
• Slow: Ventilate patients at 8-10 breaths per minute. The less you ventilate the less time the patient spends with positive ITP. Observational studies have demonstrated that providers ventilate too fast during code so the use of a metronome or timing light provides critical feedback.

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Question

What’s the name of this CT finding and name two potential causes?

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Sever's disease also known as calcaneal apophysitis, is the most common cause of heel pain in the young adolescent (ages 8 to 12).

It can be thought of as the Achilles tendon equivalent of Osgood-Schlatter's disease (patellar tendon insertion pain).

It is a non inflammatory chronic repetitive injury.

Commonly seen bilaterally in up to two -thirds of cases.

Patients will complain of activity related pain to the heel.

There may be tenderness and local swelling at the Achilles tendon insertion.

Radiographs are not necessary for acute cases.

Treat with activity modification, heel raise, physical therapy.

Caffeine is the most commonly used psychoactive substance in the world. It is widely available in coffee, tea, chocolate,soft drinks, OTC medicines, and energy drinks. The vast majority of people consuming caffeine appear to suffer no harm while enjoying it's stimulating effects. This has led to the widely held perspective that caffeine is a completely benign substance with no adverse health effects exists.

Although, children and adolescents are at particular risk, many caffeine containing products are specifically marketed at them. Alarmingly, statistics demonstrate that caffeine intake among children and adolescents has increased by 70% in the last 30 years. Energy drinks are of special concern as they represent the fastest growing component of the beverage industry, contain significant quantities of caffeine as well as high levels of sugar, and can place children at high risk for caffeine intoxication.

There are many negative health consequences documented with caffeine use which occur in a dose dependent manner with individuals differing in their susceptibility to caffeine-related adverse effects:

• Arrhythmias
• Anxiety
• Agitation
• Seizure
• Nausea,vomiting, diarrhea
• Diuresis
• Metabolic disturbances
• Hypotension
• Rare fatalities

Chronic Effects:

• Insomia
• Palpitations
• Headaches
• Diuresis
• Gastric acid secretion
• Urinary incontinence in women
• Adverse effect on wound healing process, the aging process of the human skin
• Low birth weight babies
• Withdrawal state
• Increased risk of cardiovascular events (heart attack,strokes, peripheral artery disease and kidney failure) in young adults with mild hypertension.

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Every year approximately 265,000 people die from burns

·      The vast majority occur in low- and middle-income countries

o   The rate of child death from burns is 7 times worse in low- and middle-income countries compared to high income countries

·      Almost half of all fatal burns occur in the WHO South-East Asia Region

Non-fatal burns are a leading cause of global morbidity

·      In 2004, almost 11 million individuals worldwide were burned badly enough to require medical attention

Unlike many other unintentional injuries, burns occur:

·      Mainly in the home and workplace

o   Women are at greater risk secondary to open fire cooking

·      Approximately equally among men and women

o   Most other injuries occur more frequently in men

Most burns are preventable.  Developing an effective burn prevention plan involving multiple sectors is important.  Per the WHO, the plan should be broad with efforts to:

·      improve awareness

·      develop and enforce effective policy

·      describe burden and identify risk factors

·      set research priorities with promotion of promising interventions

·      provide burn prevention programmes

·      strengthen burn care

·      strengthen capacities to carry out all of the above.

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Happy New Year!!!

My new year's resolution is to use less antibiotics (and eat more Cap'n Crunch Berries)

Will I be successful?

A multi-center, ICU, observational study looking at over 900 patients from 67 ICUs showed that half of all empiric antibiotics ordered in patients are continued for at least 72 hours in the abscence of adjudicated infection.

• We have been well trained to start antibiotics but stopping or limiting use can be difficult
• The greater the severity of illness, the longer the antibiotics were continued in this study

Things to consider:

The same way we try and limit central line use, we should try and decrease antibiotic usage on a daily basis

Tips to decrease use: daily clinical pharmacist input, ID specialist involvement, automated stop dates, 72 hour vancomycin cessation protocols, incentives for de-escalation, educational resources

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After three failed attempts, the FDA finally granted approval for Merck's non-depolarizing neuromuscular blocker reversal agent sugammadex (Bridion). Though the product has been used in Europe and Asia for several years, hypersensitivity concerns led to the delayed approval in the U.S.

Important points

1. Reverses rocuronium, vecuronium, and to a lesser degree, pancuronium
2. Full reversal obtained about 3 minutes after administration
3. Eliminated entirely by the kidneys in about 8 hours (6 times longer in patients with CrCl < 30 mL/min)
4. Dosing is generally 2-4 mg/kg. Total body weight should be used in obese patients

Application to Clinical Practice

1. Potential for use in situations where a neuro exam is needed shortly after intubation (eg, status epilepticus, ICH)
2. The risk of serious hypersensitivity appears to be < 1% in published literature
3. Cost will most assuredly be high
4. Long duration in patients with reduced kidney function means further attempts to re-paralyze with roc, vec, or pancuronium may be unsuccessful

The EM PharmD blog discusses sugammadex's approval in more detail.

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Many providers may not be familiar with the "J-Tip" (National Medical Products Inc, Irvine, CA) which is a needle-free jet injection system that uses air to push buffered lidocaine into the skin. In theory, it provides quick local anesthesia without a needle, making it an ideal tool to reduce the pain of pediatric venipuncture. Maybe you will consider giving it a try?...but what is the data for it?

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Attachments

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In many countries, alcohol is commonly drunk for special occasions, such as New Year’s.  What can be the consequences of drinking too much?

As noted in an article on the validation of the Dutch version of the brief young adult alcohol consequences questionnaire, the most common consequences were:

1. Had a hangover: 74.3%
2. Had less energy or felt tired because of my drinking: 63.9%
3. While drinking, I have said or done embarrassing things: 38.0%
4. Felt very sick to my stomach or thrown up after drinking: 34.1%
5. Ended up drinking on nights when I planned not to drink: 29.2%
6. Not gone to work or missed classes because of drinking: 28.0%
7. Not been able to remember large stretches of time: 26.8%
8. Taken foolish risks: 24.7%
9. Quality of my work or school work has suffered: 21.7%
10. When drinking, I have done impulsive things I regretted later: 21.4%

According to the Alcohol Hangover Research Group Consensus Statement on Best Practice in Alcohol Hangover Research, items 1, 2, 4, 6 and 9 are or may be related to hangovers.

Have an enjoyable, but safe New Year.

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Acute Chest Syndrome

• Acute chest syndrome (ACS) accounts for the most common cause of ICU admission and the most common cause of death in sickle cell patients.
• Important pearls for ACS include:
  • Chlamydophila pneumonia is the most common bacterial cause of ACS in adults, whereas Mycoplasma pneumonia is the most common bacterial cause in children.
  • CXR abnormalities may be absent early in disease.
  • Children are more likely to have middle lobe disease, in contrast to adults who often have lower lobe involvement.
  • Acute RV failure is a well recognized complication of ACS - use ultrasound to evaluate the RV and be careful with fluids.

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