UMEM Educational Pearls

End Tidal CO2 continuous capnography is being utilized more in the ED for procedural sedation. One of the best studies is a randomized control trial using propofol that showed you could see signs of hypoventiliation prior to hypoxia by about 60 seconds - which can be plenty of time to get your BVM and airway cart ready.

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• While validated diagnostic tools such as the NIH Stroke Scale are often very helpful, particularly in terms of communicating with Neurologists, there are tools such as the ROSIER (Recognition of Stroke in the Emergency Room) Scale which is a brief score designed to facilitate expedited diagnostic testing and treatment of stroke in the emergency department.

• The ROSIER Scale has been found to recognize stroke with 93% sensitivity, 83% specificity, 90% positive predictive value, and 88% negative predictive value. 

• If the total score is > 0 (i.e. 1-6), then stroke is likely. If the total score is < or equal to 0, then stroke is unlikely, but can not be completely excluded.

• See attached ROSIER Scale for details.

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Attachments

• 1108241811_ROSIER_Scale_for_Stroke.doc (61 Kb)

Re-expansion Pulmonary Edema After Chest Tube Placement

• Tube thoracostomy is a common procedure in the emergency department.
• For patients who develop respiratory distress after chest tube placement, think about re-expansion pulmonary edema.
• While a rare occurrence, re-expansion pulmonary edema is reported to have a mortality rate of up to 20%.
• The mechanism by which edema forms remains controversial, but is thought to be due to increased alveolar-capillary membrane permeability in the expanding lung.
• Treatment is supportive with supplemental oxygen and diuretics.  Some patients may require mechanical ventilation depending on the degree of distress and hypoxia.

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Question

79 y.o. male lung cancer patient with tachypnea, tachycardia, and normal blood pressure. Click here: http://vimeo.com/27973006

Possible diagnosis?

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Elderly patients are high risk for missed MI because of atypical presentations. Though this seems to be relatively common knowledge, it is not always remembered. So here's a reminder....

• Elderly patients present with chest pain during their MI only ~ 50% of the time
• Dyspnea is the most common anginal equivalent (alternative complaint). Other common anginal equivalents are syncope, nausea, vomiting, or diaphoresis
• The ECG in elderly patients with AMI is more frequently non-diagnostic. Only 40% of the time do they present with a STEMI, and when they do have ST elevation it may be less elevation than with younger patients. Furthermore, baseline abnormalities such as BBB, pacers, and prior MIs may make the ECG more difficult to interpret.

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Infantile botulism

If you think the controversy was just heating up for propofol use in the Emergency Department, just wait until the new agent begins arriving to an ED near you - fospropofol. A new water soluble version of propofol, this agent will remove the problems of pain at the injection site, an easier/wider therapeutic window for sedation and allowing of long-term sedation without the heavy lipid load.

Currently, there is limited FDA approval in the US for monitored anesthesia care. I am waiting for the first paper showing its use in the ED for procedural sedation. Safety data is still growing.

     Mini-pearl: Patients allergic to soybean should either avoid propofol or undergo skin testing since the emulsion is made of soybean oil and egg lecithin. There have been reported cases of anaphylaxis after administration of propofol in patients with food allergies, peanut and birch.

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• The astute clinician should know the common causes of increased intracranial pressure (ICP) in order to recognize and treat this condition early.

• Below is a brief differential diagnoses for increased ICP due to structural abnormalities:

               -   Tumor - more likely if in lateral ventricles, posterior fossa, or intraspinal.

               -   Spina Bifida - blocked cerebrospinal fluid (CSF) flow may cause Chiari Malformation II.

               -   Congenital Aqueductal Stenosis - associated with mental retardation, abducted thumbs.

               -   Craniosynostosis - results from premature closure of skull sutures.

               -   Dandy-Walker Syndrome - cystic deformity of fourth ventricle, hypoplasia of cerebellar

                    vermis, and enlarged posterior fossa.

               -   Arachnoid Cyst - common locations include middle and posterior fossa.

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The open cricothyrotomy technique is taught as the trauma airway standard when one “cannot intubate and cannot ventilate” however, it is not without difficulty and limitations. The B.A.C.T. (Bougie-Assisted Cricothyrotomy Technique) may improve the procedure by using a bougie to assist.

Steps for the B.A.C.T. (as described in the paper):
1. Stabilize the larynx with the thumb and middle finger, then identify the cricothyroid membrane.
2. Make a transverse stabbing incision with a scalpel through both skin and cricothyroid membrane.
3. Insert tracheal hook at the inferior margin of the incision and pull up on the trachea.
4. Insert a bougie through the incision with curved tip directed towards the feet
5. Pass 6-0 endotracheal tube or Shiley over bougie into trachea.

Advantages of a bougie:
1. Thin and easy to insert into incision
2. Tactile feedback from tracheal rings confirms proper placement
3. Ensures that stoma will not be lost during procedure

EMRAP.tv has a great video of Dr. Darren Braude demonstrating the procedure;
http://bit.ly/nB3BMG

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The most common sources of bacteremia and serious bacterial infections in the elderly are the GU tract, the respiratory tract, and #3-the abdomen.

This third source is a bit of a surprise to many clinicians but worth remembering. Always consider the abdomen as the source of dangerous infections in the elderly when the source is not clearly the lungs or urine!

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Acute brachial plexus neuritis is an uncommon disorder that is easily confused with cervical radiculopathy.

Patients present with a characteristic pattern of acute onset of burning pain.  Pain subsides in days to weeks and is then followed by profound weakness and muscle wasting changes affecting the shoulder  and upper extremity. Weakness is best identified in the deltoid, biceps and rotator cuff muscles. Strength gradually recovers over 3-4 months.

DDX:  The constellation of pain, weakness and sensory loss associated with cervical radiculopathy tend to occur simultaneously.  Also cervical radiculopathy tends to involve only a  single root.

ED treatment is with analgesics and physical therapy and PCP referral for outpatient MRI/EMG. Consider a sling in those with severe shoulder weakness.

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Caffeine can interfere with the successful reversion of paroxysmal supraventricular tachycardia (SVT) by adenosine.

Caffeine is an adenosine receptor blocker.

Ingestion of caffeine less than 4 hours before a 6-mg adenosine bolus significantly reduced its effectiveness in the treatment of SVT.  Theophylline is similar but not many patients are prescribed it anymore.

An increased initial adenosine dose may be indicated for these patients. A first dose of 12 mg (instead of 6), followed by 2nd and 3rd doses of 18 mg (instead of 12) may be indicated.

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• Infectious disease guidelines recommend that antibiotics be administered to patients in whom bacterial meningitis is suspected within 30 minutes of their presentation.
• Antibiotics do not appear to cause changes in cerebrospinal fluid (CSF) white blood cell, protein, or glucose levels which are compatible with impeding diagnostic utility.
• Additionally, CSF gram stain findings are not significantly changed by early antibiotic use, as these studies have been found to be diagnostic in most patients even if lumbar puncture (LP) is delayed by up to 3 days. 
• CSF cultures may be positive even after a single dose of antibiotics, although the yield decreases with more fastidious organisms such as meningococcus.
• In 86% of patients with bacterial meningitis, the causative organism may be isolated pre-antibiotic administration via blood culture.
• TAKE HOME POINT:  In cases of high suspicion for bacterial meningitis, do not delay administering antibiotics for the sake of first performing an LP, and have a low threshold to check blood cultures.

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When may an ED thoracotomy be futile?

• Performing an ED thoracotomy is incredibly stressful and a resource-intense procedure.
• While we've all learned that stab wounds to a ventricle have the highest survival rate, what about indicators that an ED thoracotomy may be futile?
• A recent study of 18 trauma centers across the US found that ED thoracotomy was unlikely to yield productive survival in the following:
  • Blunt trauma patients that require > 10 min of prehospital CPR without response
  • Penetrating trauma patients that require > 15 min of prehospital CPR without response
  • Patients presenting in asystole without evidence of pericardial tamponade on bedside ultrasound.

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Question

13 year-old right-hand dominant male following assault with blunt object. Diagnosis?

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Here are a few important points to keep in mind when evaluating elderly patients in the ED or when prescribing a new drug:

• Adverse drug effects lead to 11% of ED visits in patients > 65
• Older patients in the ED generally take > 4 medications per day, with 13% taking > 8 medications
• 11% of elderly patients in the ED receive at least 1 inappropriate medication
• 3 medication classes account for 48% of all ED visits for adverse drug effects in the elderly: oral anticoagulants or antiplatelet meds, antidiabetic medications, and agents with a narrow therapeutic index (e.g. digoxin, phenytoin)

Pay special attention to medication lists and new prescriptions in the elderly....much more attention than with younger patients!

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• We often see seizure patients on phenytoin therapy who have subtherapeutic levels.  Most patients do not require intravenous loading and can be adequately managed with oral treatment.
• To estimate what dose to prescribe, use the following equation: [0.7 x IBW x (15 - current level)].  For example if a 70 kg patient has a level of 8 mcg/mL (mg/L), we would need ~400 mg loading dose to achieve a level of 15.
• Phenytoin is known for its erratic absorption and propensity for causing GI upset with doses too high.  The recommended strategy is to avoid administering more than 400 mg at one time and separate the doses by 2 hours.  This would take three doses over 4 hours for a 1 gm load.
  • In the ED, an effective strategy for a 1 gm oral load is 500 mg now and 500 mg in 2 hours at discharge.  Patients tolerate it well, it cuts down on ED length of stay, and still achieves therapeutic levels.  Remember that an oral suspension formulation is also available.

1)      C-A-B for CPR. Now recommended to start compressions immediately instead of the conventional rescue breaths.

2)      Capnography during CPR. Continuous capnography recommended during CPR to guide the resuscitation, especially the effectiveness of chest compressions.

a.     If ETCo2 is less than 10 to 15 mm Hg consistently, focus your efforts on improving chest compressions.

3)      Etomidate for RSI induction.  Okay to use in infants and children, BUT not recommended for pediatric patients in septic shock.  Etomidate was not addressed in 2005 guidelines.

4)      Cuffed ET tubes. Acceptable to use in infants and children.

5)      Limit FiO2 after resuscitation.  Keep O2 sats ≥94%.  Avoid hyperoxia.

6)      Therapeutic hypothermia after cardiac arrest.  Recommendation based off of adult data, no pediatric prospective RCT done on this.  This is beneficial in adolescents with out-of-hospital VF arrest.

a.      Consider therapeutic hypothermia for infants and children.

b.      Cool to 32^oC-34^oC                                      

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o   The FDA is now asking manufacturers to limit the amount of acetaminophen in combination products to 325 mg per dose.

o   The higher dose formulations will be phased out by 2014.

o   The FDA is also considering lowering the maximum total to 3 gm per day, and a maximum dose of 650 mg per dose

o   This does not pertain to OTC, but this is likely to change in the near future; Johnson & Johnson (manufacturer of Tylenol) has already adopted these recommendations.

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