Keywords: Concussion, return to play, school, head injury (PubMed Search)
You have successfully diagnosed a concussion, explained everything to the parents, closed the encounter, reached for the doorknob and….
“What about school?”
An athlete should not return to play until they have successfully returned to school
Several studies have demonstrated that intense cognitive stimulation and intense intellectual stimulation result in worsening symptoms
-school work, TV, videogames, texting
Attempt to limit cognitive activity to the point where it begins to reproduce or worsen symptoms!
Step 1: 24 to 48 hours of rest
Step 2: Daily at home activities that do not increase symptoms. Starting with 5 – 10 minutes and gradually build up to a goal of tolerating 30 minutes of cognitive activity without worsening symptoms.
Home work, reading assignments, other cognitive activities
Step 3: Attempt Return to school (will not be completely symptoms free!) with either part time, partial days, or with extended breaks. Goal of tolerating an entire school day without symptoms.
Most students recover fully within 4 weeks and adjustments can then be discontinued. Others with ongoing symptoms may require ongoing academic modifications (extra time for tests, papers, etc).
Suggested examples of adjustments: Shortened days, 15 minute break for every 30 minutes of instruction, providing class notes, tutoring, decreasing course expectations, decreasing exposure to classes which exacerbate symptoms, no computer work, untimed tests and quizzes, lunch in a quiet place.
Bass & Valasek Auguest 2018 Contemporary Pediatrics
Keywords: stroke, TIA, antiplatelet, aspirin, clopidogrel, POINT, CHANCE (PubMed Search)
Does using a combination of aspirin and clopidogrel decrease your patient’s risk of recurrent stroke after a minor ischemic stroke or high risk TIA event?
Bottom Line: The use of DAPT in minor ischemic stroke and high risk TIA reduces the risk of recurrent stroke. However, the duration of DAPT may affect the risk of major hemorrhage.
|Trial||POINT (Johnston et al, NEJM 2018)||CHANCE (Wang et al, NEJM 2013)|
N. America, Europe, Australia, New Zealand
(82.8% enrolled in the US)
Age ≥ 18
Within 12 hours of sympton onset
NIHSS ≤ 3 or TIA with ABCD ≥ 4
Age ≥ 40
Within 24 hours of symptom onset
NIHSS ≤ 3 or TIA with ABCD ≥ 4
|Study Group|| |
Clopidogrel 600mg load, then 75mg daily x 90 days
Aspirin 50-325mg daily x 90 days
Clopidogrel 300mg load, then 75mg daily x 90 days
Aspirin 75mg daily x 21 days
|Control Group|| |
Aspirin 50-325mg daily x 90 days
Aspirin 75mg daily x 90 days
|Primary Efficacy Outcome||Major ischemic event defined as cardiovascular death, stroke, MI||Stroke (ischemic or hemorrhagic)|
|Primary Safety Outcome||Major hemorrhage defined as symptomatic ICH, intraocular bleeding causing vision loss, transfusion ≥ 2 units PRBCs, hospitalization/death related to hemorrhage|| |
Moderate hemorrhage defined as transfusion requirement
Severe hemorrhage defined as fatal, ICH, hemodynamic compromise
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Category: Critical Care
Keywords: High flow nasal cannula, acute respiratory failure, hypoxia, hypercarbia, non-invasive ventilation (PubMed Search)
We know that high flow nasal cannula is an option in the management of acute hypoxic respiratory failure without hypercapnea. A newer iteration of high flow, "high velocity nasal insufflation" (HVNI), may be up-and-coming.
According to its makers (Vapotherm), it is reported to work mainly by using smaller bore nasal cannulae that deliver the same flows at higher velocities, thereby more rapidly and repeatedly clearing dead space, facilitating gas exchange and potentially offering ventilatory support.
In an industry-sponsored non-inferiority study published earlier this year:
The availability of a nasal cannula that helps with CO2 clearance would be great, and an option for patients who can't tolerate the face-mask of NPPV would be even better.
HVNI requires more investigation with better studies and external validation before it can really be considered noninferior to NPPV, but it certainly is interesting.
Category: Pharmacology & Therapeutics
Keywords: Clonidine, opioid withdrawal (PubMed Search)
Clonidine is an alpha-2 agonist commonly used to treat hypertension. Clonidine can also be used to mitigate symptoms of opioid withdrawal as it easily crosses the blood brain barrier and reduces sympathetic effects.
When using clonidine for acute withdrawal or blood pressure control, oral tablets are the preferred route. Clonidine transdermal patches have slow absorption and take 2-3 days for the effect to be seen. Once removed, clonidine patches can provide therapeutic levels for up to 20 hours.
Bottom Line: If clonidine is needed acutely for your patient, select oral tablets and titrate to effect.
Catapres-TTS [package insert] Boehringer Ingelheim Pharmaceuticals, Inc. Ridgefield, CT, August 2016.
Keywords: weakness, sensory symptoms, MRI, LP (PubMed Search)
Frohman EM, Wingerchuk DM. Clinical practice. Transverse myelitis. N Engl J Med. 2010;363(6):564-572.
de Seze J, Lanctin C, Lebrun C, et al. Idiopathic acute transverse myelitis: application of the recent diagnostic criteria. Neurology. 2005;65(12):1950-1953.
Keywords: thrower, insability (PubMed Search)
25yo baseball pitcher presents with medial elbow pain. He felt a painful “pop” and could not continue to throw (due to loss of speed and control). Mild paresethesias in 4th and 5th digits.
What physical examination maneuvers can you do at the bedside to assist in the diagnosis?
Exam opposite elbow first to establish baseline and to assist patient relaxation and understanding.
Flexing elbow to 20 to 30 degrees unlocks the olecranon
Keywords: West syndrome, seizures (PubMed Search)
Originally described a Dr. West in 1841 – it is a rare (~1200 cases annually) seizure disorder in young kids, generally less than 1 year old. Very subtle appearance, often with only bending forward or ‘jerking’ of the extremities as opposed to Brief Resolved Unexplained Event (BRUE) or tonic-clonic in description. The spasms can be thought of as a syndrome, where 70% of those have an undiagnosed rare metabolic/genetic disease.
A prompt evaluation, including labs, EEG, MRI, metabolic and genetic studies is vital in helping to establish a diagnosis which can have a profound impact on the patients prognosis. Examples might include Tuberous Sclerosis, Pyridoxine Dependent Seizures among over 50 others.
Bottom line: In pediatric patients less than 1 year old who present to the Emergency Department with a description of spasm-like episodes, consider Infantile Spasms on the differential, and consult your friendly neighborhood Pediatric Neurologist for help in determining a proper disposition.
Keywords: Fever, pain control, ibuprofen, acetaminophen (PubMed Search)
Walsh P, Rothenberg S, Bang H. Safety of ibuprofen and infants younger than 6 months: A retrospective cohort study. PLos ONE 13 (6):e019493.
Keywords: Anticholinergic, Plant (PubMed Search)
A 19 year old male presents confused and very agitated complaining of seeing things and stomach pain. His friends report he ingested a naturally occurring plant to get high a few hours ago but is having a "bad trip". His physical exam :
Temp 100.3, HR 120, RR 14, BP 130/88. Pulse Ox 98%.
Skin: Dry, hot , flushed
HEENT: Marked mydriasis 6mm
Abdomen: Distended tender suprapubic with absent bowel sounds,
Neuro: Extremely agitated pacing, no muscular rigidity.
What has he ingested and what is the treatment?
Datura stramonium, aka: Jimson Weed, flowers in the summer with white to violet trumpet petals, green irregular toothed leaves, and a green thorny round walnut sized seed pod (aka: thorn apple) the base of the stem. In the fall, the seed pods turn brown and split open to reveal chambers that are packed with dozens of small black seeds containing the anticholinergic tropane alkaloids, atropine, hyoscyamine, and scopolamine.
All parts of the plant are toxic and it has long been used in traditional medicine. Toxicity consists of anticholinergic toxidrome: Delirium and agitation, visual hallucinations, dry flushed skin, hyperthermia, mydriaisis, tachycardia, absent bowel sounds, urinary retention, remembered by the pneumonic "Red as a beet, hot as a hare, dry as a bone, blind as a bat, mad as a hatter, the bowel and bladder lose their tone, and the heart runs alone" . Toxicity is usually 12 hours but can be quite prolonged.
Treatment consists of :
-Gastric decontamination with activated charcoal and whole bowel irrigation for seed ingestion (seeds get caught up in gastric folds prolonging toxicity)
-IV Physostigmine, a reversible short acting acetylcholinesterase inhibitor increases acetylcholine at the synaptic clef, crosses the blood brain barrier, and is antidotal. Physostigmine has been demonstrated to be more effective and without significant complications when compared with benzodiazepines for the diagnosis and treatment of anticholinergic agitation and delirium. Usual dose is 0.5-2 mg with repeat dosages as needed.
Category: Critical Care
Sedating Mechanically Ventilated Patients
Keywords: Concussion, minor head injury, traumatic brain injury, mTBI (PubMed Search)
The Centers for Disease Control and Prevention recently released guidelines on the diagnosis and management of mild traumatic brain injury (mTBI**) among children. From 2005-2009, children made almost 3 million ED visits for mTBI. Based on a systemic review of the literature, the guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI.
1. Do not routinely image patients to diagnose mTBI (utilize clinical decision rules to identify children at low risk and high risk for intracranial injury (ICI), e.g. PECARN)
2. Use validated, age-appropriate symptoms scales to diagnose mTBI
3. Assess evidence-based risk factors for prolonged recovery. No single factor is strongly predictive of outcome.
4. Provide patients with instructions on return to activity customized with their symptoms (see CDC Resources below)
5. Counsel patients to return gradually to non-sports activities after no more than 2-3 days of rest.
A wealth for information and tools for provder and families can be found at:
www.cdc.gov/HEADSUP (including evaluation forms and care plans for providers)
**Although concussion, minor head injury, and mBI are frequently used interchangeably, they have different connotations which allows for misinterpretation and confusion. The guideline recommends the clinical use of the single term mild traumatic brain injury. This is defined as "an acute brain injury resulting from mechanical injury to the head from external physical forces including: (1) 1 or more of the following: Confusion or disorientation, loss of consciousness for 30 minutes or less, posttraumatic amnesia for less than 24 hours, and/or other transient neurologic abnormality such as focal signs, symptoms, or seizure; (2) Glasgow Coma Scale score of 13-15 after 30 minutes post injury or later upon presentation for healthcare
Diagnosis and management of mild traumatic brain injury in children: A systemic review. Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, Turner M, Benzel EC, Suskuer SJ, Giza CC, Joseph M,Broomand C, Weissa B, Gordon W Wright DW, Moser RS, McAvoy K, Ewing-Cobbs L, Duaime AC, Putukian M, Holhouse B, Paulk D, Wade SL, Herig SA, HalsteadM, Keenan H, Choe M, Christia CW, Gusiewic K, Raksin PB, Gregory A, Mucha A, Taylor HG, Callahan JM, DeWtt J, Collins MW, Kirkwood MW, Ragheb J, Ellenbogen RG, Spinks TJ, Ganiats TG, Sabelhaus LJ, Altenhofen K, Hoffman , Getchius T, Gronseh G,Donnell Z, O'Connor RE, Timmons SD JAMA Pediatr 2018 Sept 4.
Keywords: anaphylactoid reaction, IV NAC (PubMed Search)
Analphylatoid reaction is caused by non-IgE mediated histamine released. Intravenous N-acetylcysteine (NAC) infusion is well known to cause analphylatoid reaction. However, it’s incidence is unknown.
Recently, a large retrospective study of all patients who received 21-hour IV NAC in 34 Canadian hospitals (1980 to 2005) was performed.
Anaphylactoid reaction was documented in 528 (8.2%) of 6455 treatment courses
Over 90% patients developed analphylatoid reaction within 5 hours.
Onset of reaction:
Administered medication for treatment
Patient characteristics that were associated with higher incidence of Anaphylactoid reaction includes
Yarema M et al. Anaphylactoid reactions to intravenous N-acetylcysteine during treatment for acetaminophen poisoning. J Med Toxicol 2018: Jun;14(2):120-127. doi: 10.1007/s13181-018-0653-9. Epub 2018 Feb 8.
Category: Critical Care
Keywords: acidosis, acidemia, sodium bicarbonate, shock (PubMed Search)
The recently published BICAR-ICU study looked at the use of bicarb in critically ill patients with severe metabolic acidemia...
Consider administration of sodium bicarbonate for your critically ill ED patients with severe metabolic acidosis and AKI, especially if acidosis &/or renal function is not improved with usual initial measures (such as IVF, etc).
*Acute Kidney Injury Network Staging Criteria
Jaber S, Paugam C, Futier E, et al. Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomised controlled, phase 3 trial. Lancet. 2018;392(10141):31-40.
Keywords: Ulnar nerve (PubMed Search)
Tests for motor weakness of the Ulnar nerve
Patient asked to hold piece of paper in both hands, grasping with the thumb and radial side of index finger of both hands
Examiner then pulls on the paper
Test is positive if patient flexes the thumb IP join in an attempt to hold onto paper
Category: Critical Care
Does Lactated Ringer's Raise Serum Lactate?
Zitek T, et al. Does intraveneous lactated ringer's solution raise serum lactate? J Emerg Med. 2018; 55:313-8.
Keywords: wounds, trauma, procedure (PubMed Search)
Many elderly patients have thin skin making suture repair of lacerations difficult. Consider using Steri-Strips™ in combination with sutures to close fragile skin tears.
1. Apply Steri-Strips™ perpendicular to the wound in order to approximate skin edges.
2. Place sutures through both the applied Steri-Strips™ and skin and knot the suture.
This technique will help prevent the suture from tearing the skin as the tension of the suture will be distributed across the surface area of the Steri-Strips™.
Davis M, Nakhdjevani A, Lidder S. Suture/Steri-Strip Combination for the Management of Lacerations in Thin-Skinned Individuals. The Journal of Emergency Medicine. 2011;40(3):322-323. doi:10.1016/j.jemermed.2010.05.077.
Category: Pharmacology & Therapeutics
Keywords: Sepsis, Antibiotics, CMS, Core Measures (PubMed Search)
The Centers for Medicare and Medicaid Services (CMS) require broad spectrum antibiotics to be administered within 3 hours of presentation of sepsis to be in compliance with the sepsis measure.
Not only do the antibiotics that are chosen determine compliance with this measure, but the order in which antibiotics are given can also significantly affect compliance.
According to CMS, for combination antibiotic therapy, both antibiotics must be started within the three hours following presentation; however, they do not need to be completely infused within this time frame.
Combination therapy typically includes a monotherapy antibiotic (see list in detailed information below) plus vancomycin (daptomycin or linezolid could also be used).
So which antibiotic should be given first?
If a monotherapy antibiotic is given first within the 3 hours of presentation, then compliance for the sepsis measure is met. These antibiotics cover a broader range of bacteria and are typically infused over ~30 minutes, which allows plenty of time for your second antibiotic to be initiated.
If vancomycin is given first, compliance with this measure can become difficult. First, vancomycin has a narrower spectrum of activity and is not a monotherapy antibiotic. Second, vancomycin infusion rates range from 1 to 2 hours. Given that antibiotics are usually given after sepsis is flagged, this infusion rate only gives a short period of time for the second antibiotic to be initiated. Thus, vancomycin should almost always be the second antibiotic infused.
In addition, patients may also have limited intravenous access or antibiotics may not be compatible with resuscitation fluids. All of these factors together must be considered when trying to gain compliance with this measure.
Administer monotherapy antibiotics (e.g. piperacillin/tazobactam and cefepime) prior to administering vancomycin in your septic patients to improve compliance with the sepsis measure.
Specifications Manual for National Hospital Inpatient Quality Measures v5.4. The Joint Commission. https://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx. Updated December 29, 2017. Accessed August 31, 2018.
Bachur, R. Comparison of acute treatment regimens for migraine in the emergency department. Pediatrics.2015;135(2)232-238.
Gelfand, A. Treatment of pediatric migraine in the emregency department. Ped Neuro.2012;47(4)233-241.
Kacperski, J. The optimal management of headaches in chidlren and adolescents. Ther Adv Neuro Disor. 2016;9(1)53-68.
Sheridan, D. Pediatric Migraine: Abortive treatment in the emergency department. Headache. 2014;54(2):235-245.
Keywords: Weakness (PubMed Search)
A 68 year old male presents to the ED complaining of weakness to his legs. He states today his yard chores took him over 2 hours to complete instead of the usual 15-20 minutes due need to take frequent breaks for rest due to leg pain. He denied any chest pain or shortness of breath. Past medical history included hypercholesteremia, HTN, and CAD. He is taking aspirin and recently started on rosuvastatin.
His physical exam was unremarkable.
Results showed normal EKG and CBC. Bun was 70, Creatinine was 3.4, and CPK of 1025.
This patient has statin induced rhabdomyolysis and acute renal failure.
Take Home Points:
Category: Airway Management
Keywords: foot, necrosis (PubMed Search)
Osteonecrosis of the tarsal navicular bone
Affects children ages 4 to 7
4x more likely in males
Can be painless or present with arch/midfoot pain and a limp (usually activity related)
Usually unilateral but can be bilateral (in up to 25%)
PE: Tenderness to palpation over the length of the arch esp the medial navicular
Swelling, warmth, redness
-Can be misdiagnosed as an infection
X-ray: Sclerosis, collapse/flattening or fragmentation of navicular
Treatment: Walking boot or short leg cast