UMEM Educational Pearls

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Building on Dr. Winter's pearl from a couple of weeks ago, this is more evidence that a one-size-fits-all approach to fluid volume for resuscitation in sepsis doesn't fit.
This update to a previous systematic review and meta-analysis of 17 trials concluded that lower-volume IV fluid goals "probably result in little to no difference in all-cause mortality" or "little to no difference in serious adverse events" compared with higher IVF volumes.  
Summary: This is yet another study suggesting that a lower fluid volume goal is probably better, or at least isn't harmful, but is not the pratice-changing paper everyone is looking for.
Happy Thanksgiving Everyone!
 
 
 
 
 

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Category: Trauma

Title: Geriatric vs. Super-geriatric Trauma

Keywords: Geriatric, older person, trauma, super-geriatric (PubMed Search)

Posted: 11/23/2023 by Robert Flint, MD (Updated: 6/14/2024)
Click here to contact Robert Flint, MD

This retrospective study looked at trauma patients over age 65 and divided them into age ranges 65-80 (geriatric) and 80 plus (super-geriatric). They then looked at mechanusm of injury, mortality, interventions,etc. What they found was ages 65-80 were more likely to be injured in motor vehicle crashes vs. falls for those over 80. Those over 80 received less interventions including hemmorhage control surgery and had much higher levels of withdrawal of care. 

This study highlights that the geriatric population is not as a monolithic group over age 65, but more nuanced by various age ranges over 65. Research going forward should be adjusted to these nuanced age ranges. Out treatment approaches should be adjusted in geriatric vs. super-geriatric patients as well. 

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Category: Administration

Title: ED Boarding Insights

Keywords: boarding, administration, crowding (PubMed Search)

Posted: 11/22/2023 by Mercedes Torres, MD (Updated: 6/14/2024)
Click here to contact Mercedes Torres, MD

A recently published study of ED APPs, residents, attendings, and nurses attempted to assess clinician's perspectives on how ED boarding impacts ED staff and patients.  Authors performed a survey followed by focus group sessions to obtain qualitative insignts from participants. 

All respondents associated boarding with feelings of burnout and self-reported poor satisfaction with communication and the process of boarding care.

Several key themes emerged which are outlined below:

  1. Clinicians perceived that boarding leads to increased patient safety events.
  2. Clinicians desired standardization for the boarding care process.
  3. Clinicians felt they had a lack of knowledge, resources, and training to care for boarding patients.
  4. Clinicians desired proactive bed and resource planning for boarding patients.
  5. Clinicians advocated for improved communication among the team and to patients.
  6. Clinicians identified a need for culture change regarding boarding care.

This publication highlights the negative workforce and patient safety effects of ED boarding.  It amplifies the voices of our colleagues who work towards change to improve both the health of our wrokforce as well as that of our patients and the communities that we serve.

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Category: Pediatrics

Title: Pediatric Lung Ultrasound

Keywords: POCUS, Pediatrics, Lung Ultrasound, Bronchiolitis (PubMed Search)

Posted: 11/20/2023 by Alexis Salerno, MD
Click here to contact Alexis Salerno, MD

Acute bronchiolitis (AB) is a common cause of respiratory tract infections in infants. A recent study looked at the application of Point-of-Care Lung Ultrasound (LUS) in infants <12 months who presented with symptoms of AB. 

They scored infant lungs using a cumulative 12-zone system. With the below scale: 

0 - A lines with <3 B lines per lung segment. 

1 - ≥3 B lines per lung segment, but not consolidated. 

2 - consolidated B lines, but no subpleural consolidation. 

3 - subpleural consolidation with any findings scoring 1 or 2. 

 

They found that infants with higher LUS scores had increased rates of hospitalization and length of stay.  

Here are some tips for ultrasounding a pediatric patient: 

 

  • Attempt to warm the gel
  • Have the parent/relative hold the patient while scanning
  • For those old enough, allow the child to investigate the ultrasound probe prior to placing the probe on the child.
  • Destract the child while performing scanning

 

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Category: Trauma

Title: Use of reverse shock index times GCS to predict Peds trauma needs

Keywords: Reverse shock index, Peds trauma, prediction (PubMed Search)

Posted: 11/18/2023 by Robert Flint, MD (Emailed: 11/19/2023)
Click here to contact Robert Flint, MD

This small study suggests using reverse shock index times the Glasgow Comma Scake score may give a prognostication on pediatric trauma severity and resource utilization. 
 

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This disturbing study out of the UK details the prevelance of sexual harassment, sexual assault and rape within the hospital environment.  

Overall it's clear that women surgeons in this study were the victims and witnesses of sexual violcence at a substantially higher rate than men.  89% on women report being witnesses of sexual harassment and 63% being the victim of it; 30% of women report being the victim of sexual assault, and 35% report being witness to it; and most concerning 0.8% of women report being raped by a colleague, with 1.9% being witness to it.

The study also asked respondents about their faith in higher organizations' (the Royal Colleges and the General Medical Council) ability to respond to these issues.  For women, the percentage of people who felt that there was an adequate response was only between 15-30 percent.

There is a huge and persistent gap between men and women both witnessing and experiencing sexual harassment and assault at work.  Everyone has a responsibility to immediately interrupt any form of sexual harassment or assault, no matter how inocuous it may seem to the perpertrator, in order to provide an environment we can all thrive in.

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Category: Pediatrics

Title: Does the timing of patient transfer impact mortality in the pediatric trauma patient?

Keywords: pediatric trauma, transport, time to destination (PubMed Search)

Posted: 11/17/2023 by Jennifer Guyther, MD (Updated: 6/14/2024)
Click here to contact Jennifer Guyther, MD

Pediatric patients treated at pediatric specific trauma centers have improved mortality.  However, it is estimated that only 57% of patients live within 30 miles of a pediatric trauma center.  This means that many children will need to be stabilized at an adult trauma center or community hospital prior to transfer.  This study showed that > 25% of injured children were transferred to a pediatric trauma center following stabilization at another hospital.
 
The American College of Surgeons has previously recommended that the optimal interfacility transfer time for trauma patients is 60 minutes.
 
Data for this study was extracted from a database fed by over 800 trauma hospitals.  Every minute increase in the interfacility transfer time is associated with a 2% increase in risk adjusted odds of mortality among severely injured pediatric trauma patients.
 
Bottom line: When faced with a moderate to severely injured pediatric trauma patient, the availability and time to transport should be taken into account. If the time is > 60 minutes, then mode of transport and destination (if others are available), should be considered.

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Category: EMS

Title: EMS and the management of pediatric agitation

Keywords: mental health, excited delirium, agitation, sedation, ketamine (PubMed Search)

Posted: 11/15/2023 by Jennifer Guyther, MD (Updated: 6/14/2024)
Click here to contact Jennifer Guyther, MD

This is a retrospective review of pediatric patients with mental health presentations to EMS in Australia.  For children 12 or older, EMS has standing orders for midazolam for mild to moderate agitation and ketamine for severe agitation.  Patients younger than 12 require medical consultation prior to administration.
14% of pediatric EMS calls in this study were for mental health problems.  In 8% of the 7816 pediatric mental health EMS encounters, patients received either midazolam (about 75%) or ketamine (25% of cases). 11% of patients who received midazolam had an adverse event while 37% in the ketamine group had an adverse event.  Adverse events included airway obstruction requiring jaw thrust, OPA or NPA placement, BVM or desaturations requiring oxygen. No serious adverse events occurred in either group.
Police accompanied EMS in 82% of these cases.  Patients who received medication management were more likely to have autism spectrum disorder, post traumatic stress disorder, intellectual disability, psychiatric disorder or history of substance abuse.
Bottom line: Pediatric mental health is a significant global problem where further research is needed.

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Category: Trauma

Title: Ketamine, ICP and pediatric brain injury

Keywords: Brain injury, ketamine ICP (PubMed Search)

Posted: 11/12/2023 by Robert Flint, MD
Click here to contact Robert Flint, MD

This pediatric ICU study measured ICP during and after ketamine infusion.  There was no increase in ICP associated with the ketamine infusion. This small study adds to the data that ketamine is safe in pediatric brain injured patients. 

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"I was kicked in the inside of my knee while it was straight (extended). Look at the x-ray and tell me if its bad"

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Category: Critical Care

Title: Steroids for Pneumonia? Here we go again...

Keywords: Pneumonia, Corticosteroids, Steroids, Respiratory Failure, Infection (PubMed Search)

Posted: 11/9/2023 by Mark Sutherland, MD
Click here to contact Mark Sutherland, MD

For the folks who have been in practice for a while, you may be aware of the roller-coaster evidence base looking at steroids for pneumonia.  Once thought to be beneficial and clearly indicated, of late steroids for pneumonia have fallen out of favor.  Hamad et al have published an excellent (and brief) review in Clinical Infectious Diseases which suggests the pendulum might be swinging back in favor of giving steroids to patients with pneumonia.  It's a ~5 minute read, so I recommend glancing through it yourself, but below are my two cents (solely my opinion) on where we are with steroids for pneumonia.

Take Home Points (OPINION ALERT):

1) When you have a condition present that you consider an indication for steroids (e.g. severe COVID-19 for sure; septic shock, s. pneumo infection, and ARDS depending on how you feel about the existing literature) --> strongly consider giving steroids unless there's a contraindication

2) When you have an undifferentiated patient who MAY have one of these conditions (e.g. pneumonia with COVID pending, patient potentially in ARDS or high risk of going into ARDS, etc) who is very sick --> it is reasonable to give steroids (if no contraindication) or not give steroids.  My tendency is to lean towards giving steroids in these cases, but do be aware that society guidelines recommend against steroids here (although debatable if they just haven't caught up to more recent literature)

3) When you have an undifferentiated patient who may have one of these conditions, but is NOT very sick --> I do not think there is significant enough evidence to support empiric steroids

4) Factors that might push you one way or another:

  • Severity of disease (more severe favors giving steroids),
  • Pathogen (COVID-19 and s. pneumo favor steroids),
  • What formulation of steroids you have availabile.  Some of these studies used continuous hydrocortisone infusions, for example, which most hospitals don't routinely do.
  • Comorbidities (uncontrolled diabetes, wound healing issues, risk for opportunistic infections might argue against giving steroids)

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Think before placing a nasogastric tube!

Multiple articles which discussed complications of NGT placement were included in this integrative review, with the majority (n=67) publishing results in English. The authors categorized adverse events into two broad categories:

1) Mechanical adverse events - including respiratory, esophageal, and pharyngeal complications, obstructed tube, intestinal and intracranial (!) perforation, and tube withdrawal 

-The largest cohort (n=44) was respiratory, with displacement or placement of tube to the respiratory tract

2) Others - pressure injury and misconnection

-One study showed pressure related injury in 25%, and 5 articles discussed complications of misconnection (including extravasation of gastric fluids and inadvertent connection to central venous catheters)

16 of the 69 studies reported death as a consequence of improper placement. 

One big takeaway: there is no universally accepted standard for verificaiton of tube placement. Xray is considered to be *most* accurate. Tubes should also be checked periodically and depth should be marked. Evidence-based guidelines need to be developed to improve patient safety, outcomes, and quality of care.

 

 

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Category: Trauma

Title: ECMO in Trauma

Keywords: ECMO, Trauma, Survivial (PubMed Search)

Posted: 10/14/2023 by Robert Flint, MD (Emailed: 11/4/2023) (Updated: 6/14/2024)
Click here to contact Robert Flint, MD

This systematic review and analysis found in 1822 trauma patients treated with ECMO:

-Overall 66% survival to discharge

-VV ECMO was significantly superior to VA ECMO

-Mean age was 35 years. Typical of ECMO use in trauma is younger healthier patients are chosen to receive ECMO

 

“ECMO is not a routine life-saving intervention following trauma, but rather a salvage therapy that effectively replaces conventional treatment for young, healthy patients when conventional methods fail. Its complexity requires a multidisciplinary healthcare team and sufficient resources for optimal implementation.”

 

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Category: Quality Assurance/Quality Improvement

Title: Pharmacists Make a Difference

Keywords: Medication Errors, Pharmacy (PubMed Search)

Posted: 11/4/2023 by Brent King, MD (Updated: 6/14/2024)
Click here to contact Brent King, MD

Spanish investigators conducted a 6-month, prospective, observational study to determine the impact of emergency department pharmacists on medication errors. They specifically focused on so called "High Alert" medications and on errors that, if undetected prior to administration, were likely to have serious deleterious consequences.

Over the course of the study, the pharmacists reviewed the medication records and histories of nearly 3000 patients. The pharmacists intervened in the care of 557 patients. Errors were most often detected during the process of medication reconcilliation. Over half of the potential errors were considered "severe" and the majority of pharmacist interventions were deemed important to the patient's care. Many of the medication errors detected involved "High Alert" medications.

The Bottom Line: Pharmacists are integral members of a high-functioning emergency department team. Their specialized knowledge contributes to a safe and effective care environment.

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Category: EMS

Title: EMS, Documentation, and Continuation of Care in Stroke Patients

Keywords: Stroke, EMS, medical record linkage, prehospital (PubMed Search)

Posted: 11/3/2023 by Benjamin Lawner, MS, DO
Click here to contact Benjamin Lawner, MS, DO

BACKGROUND: Prehospital (EMS) clinicians are positioned on the front lines of health care. With respect to stroke identification and treatment, early recognition is essential to positive outcomes. Considerable variability exists within EMS documentation. Despite considerable variability in documentation, the establishment and tracking of core stroke metrics serves as a benchmark to gauge performance and outline strategies for improvement. 

METHODS: Authors conducted a retrospective, observational analysis of EMS encounters (2018-2019) which ultimately received a diagnosis of an "acute cerebrovascular event." Hospital based diagnoses included: hemorrhagic stroke, ischemic stroke, or transient ischemic attack. The data set was comprised of a statewide EMS documentation and a state wide acute stroke registry. Authors examined compliance with six core performance metrics which included measurement of blood glucose, documentation of last known well time, and on-scene time < 15 mins for patients with suspected stroke. During the 18 month study, almost 6000 encounters met criteria for inclusion. 

RESULTS: EMS documentation remains a significant source of variability. EMS crews were largely compliant with blood glucose measurement. However, last known well time had the lowest (24%) documentation rate. Patients diagnosed with subarachnoid hemorrhage had the lowest rate of compliance with metrics. 

BOTTOM LINE: Accurate prehospital stroke diagnosis remains a challenge. Consistent data collection and benchmarking remains an important first step in the evaluation of performance. Higher NIHSS scores and ischemic strokes are linked to higher rates of metric compliance. 

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Category: Pediatrics

Title: Neonate Resus Review

Keywords: Neonate, Newborn, resuscitation, NRP (PubMed Search)

Posted: 11/3/2023 by Kelsey Johnson, DO (Updated: 6/14/2024)
Click here to contact Kelsey Johnson, DO

Term? Tone? Tantrum?

Immediately after delivery, your initial neonatal assessment should evaluate for:

-       Appearance of full or late pre-term gestation (>34 weeks)

-       Appropriate tone (flexed extremities, not floppy)

-       Good cry and respiratory effort

 

Newborns meeting this criteria should not require resuscitation. They can be placed skin to skin on mother and allowed to breastfeed. Delayed cord clamping for 60 seconds is recommended, as data shows improved neurodevelopmental outcomes and iron stores in first year of life.

 

Neonates not meeting these criteria should be brought to the warmer for resuscitation, with the focus being on:

-       Warm - via radiant warmer. Maintain temps 36.5 C – 37.5 C

-       Dry - Neonates have thin skin and lose heat readily from evaporative loses

-       Stim - tactile stimulation on the head, midline of the back and extremities to provoke a cry and encourage respiratory effort

 

Avoid routinely bulb-suctioning unless there is significant obstructing mucous, as this can increase vagal tone and result in bradycardia. If bulb suctioning is used, first suction the mouth before the nose.

 

Majority of resuscitations do not require additional support, however if heart rate is <100 or there is poor respiratory effort, the physician should initiate PPV.

 

PPV settings:   PIP 20              PEEP 5              FiO2 21%         Rate of 60 breaths per minute

 

Improvement in the neonate’s HR is the primary indicator of effective PPV!

If HR poorly responding (remains <100), ensure appropriate mask size, reposition, suction, and increase PIP (max 35) and FiO2.

 

If HR drops below 60, intubate with uncuffed ETT

-       Prioritize adequate ventilation as this is the highest priority in neonatal resuscitation

-       Initiate compressions at rate of 120/min.

-       Epi dosing is 0.01-0.03 mg/kg q3-5 min

-       ETT size estimation by gestational age:

        25 weeks = 2.5, 30 weeks = 3.0, 35 weeks = 3.5, 40 weeks = 4.0



IV Fluid Resuscitation

  • IVF administration is one of the most common interventions in the resuscitation of critically ill patients.
  • The primary goals of IVFs are to augment cardiac output and increase O2 delivery.
  • The amount and type of IVF must take into account the patient's pathophysiology and type of shock.
  • Sepsis remains one of the most common causes of distributive shock in the ED and ICU.
  • Large volumes of IVF in sepsis often do not increase cardiac output and frequently lead to organ congestion.
  • Rather than a fixed dose, an individualized approach to IVFs in sepsis based on the patient's history, exam, labs, monitoring, and serial reassessments is likely to lead to better outcomes. 

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Category: Trauma

Title: Does empiric high dose cryoprecipitate added to MHP improve survival?

Keywords: transfusion, mass hemorrhage protocol, cryoprecipitate (PubMed Search)

Posted: 10/14/2023 by Robert Flint, MD (Emailed: 10/29/2023) (Updated: 6/14/2024)
Click here to contact Robert Flint, MD

This large UK and US study looked at the addition of high dose cryoprecipitate to mass transfusion protocols and found:  “Among patients with trauma and bleeding who required activation of a major hemorrhage protocol, the addition of early and empirical high-dose cryoprecipitate to standard care did not improve all cause 28-day mortality.”

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Category: Orthopedics

Title: Medical encounters in Iron Man Triathlons

Keywords: Race day event, medical tent, endurance athlete (PubMed Search)

Posted: 10/28/2023 by Brian Corwell, MD (Updated: 6/14/2024)
Click here to contact Brian Corwell, MD

The objective of a recent study was to analyze the injury and illness characteristics in Iron Man distance triathletes. This information is important for emergency providers who may be asked to directly assist or help coordinate race day medical care.

Intro: The Iron Man distance triathlon is one of the most challenging ultra endurance competitions in the world. 80,000 Iron Man triathletes compete internationally each year to qualify for the Ironman world championship. The race totals 140.6 miles across three legs, beginning with a 2.4 mile swim, followed by a 112 mile cycle, and is completed with a 26.2 mile run.

Retrospective cross-sectional study of medical records from Iron Man distance championship races across a 30-year period (1989-2019). The study population (10,533) consisted of all triathletes treated at mobile medical units along the race route or who presented to the medical tent for evaluation during and immediately after the event.

Mean population age of 37 with a range of 18 to 87 years.

Results: Female athletes were found to present to the medical tent more than males (P < 0.001).

The total incidence of medical encounters by age was found to be higher in both younger athletes (18 to 34 years old) and older athletes (greater than 70 years old) versus middle-aged athletes (35-69 years old) (P < 0.001).

Professional athletes have similar overall medical encounters compared with other athletes.

The busiest hours of the medical tent were between approximately 9 and 14 hours after start time (afternoon and early evening) in which approximately 73% of athletes presented for evaluation and treatment.

Once inside the medical tent 71% of athletes were discharged within an hour and 87% were discharged within 1.5 hours. Athletes were dispatched to the hospital from the medical tent area at a rate of 17.1/1000 athletes (most athletes presenting to the medical tent finished the race and few required hospital transfer).

The most common medical complaints were dehydration and nausea followed by dizziness, exhaustion, muscle cramps, and vomiting.

Blood work was collected for 30% of athletes who entered the medical tent. Of these athletes, hyponatremia was the most prevalent diagnosis and most of whom were symptomatic with symptoms such as confusion, stupor, gait disturbance, muscle weakness, headache, dizziness, fatigue, nausea and vomiting.

Beyond basic medical care, intravenous fluids were the most common medical treatment.

Conclusion: Medical events were more frequent among female athletes as well as both younger and older age categories. Gastrointestinal and exertional related symptoms were the most common complaints in the medical tent. Besides basic medical care, IV infusions were the most common treatment. Most athletes presenting to the medical tent finished the race and only a small percentage were transferred to the hospital.

 

 

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