DOACs (dabigatran*, apixaban, rivaroxaban) each have different dosing strategies based on indication and patient characteristics. While there is no official term for the doses, the higher initial doses for apixaban (10 mg BID for 7 days) and rivaroxaban (15 mg BID for 21 days) for the treatment of venous thromboembolism (VTE) are commonly referred to as “loading doses.” However, the term “loading dose” is actually a misnomer.
Loading doses are used to reach therapeutic drug levels quicker with medications such as vancomycin and phenytoin/fosphenytoin. However, this is not the purpose of the higher initial doses of apixaban and rivaroxaban. The purpose of the higher doses is to provide increased levels of anticoagulation during the acute phase of VTE when patients are hypercoagulable. For this reason, VTE and heparin-induced thrombocytopenia are the only indications where a higher dose is used initially, all other indications start with the standard dose. The difference in duration of these higher doses between apixaban (7 days) and rivaroxaban (21 days) are due to the durations used in trials by the drug company, versus any pharmacokinetic reasons.
To apply this concept:
Apixaban/Rivaroxaban: For the treatment of VTE, a higher dose is only required for the initial 7- (apixaban) or 21-day period (rivaroxaban). After this period, if there is any interruption in therapy, the standard dose can be restarted because therapeutic levels are rapidly achieved and higher doses are not needed outside of the acute phase.
One caveat to this would be if the patient developed a new VTE while therapy is interrupted, in which case another period of the higher dosing could be considered.
*Remember: Dabigatran cannot be used for initial treatment of VTE and must be started only after at least 5 days of a parenteral anticoagulant. (Dabigatran and the parenteral anticoagulant should not be overlapped).
When patients fail simple respiratory support therapies like nasal cannula or non-rebreather, it is often a point of debate whether to move next to High Flow Nasal Cannula (HFNC) or Noninvasive Positive Pressure Ventilation (NIPPV). This study randomized patients in acute respiratory failure (ARF) to CPAP, a form of NIPPV, vs HFNC. They looked at all comers in ARF, and primary outcome was need for intubation. Importantly, they excluded asthma/COPD exacerbation, for which BiPAP is typically considered the first line therapy due to improved CO2 clearance.
They found a significantly lower number of patients required intubation in the CPAP (28.9%) group than the HFNC (42.6%) group (p=0.006). They hypothesized that the enhanced PEEP improved oxygenation (hypoxia being a common trigger for moving to intubation), but as opposed to BiPAP, the lack of additional driving pressure limited tidal volumes and Patient Self-Inflicted Lung Injury (P-SILI), which is a known mechanism of ARDS and mortality. They use this argument to explain why trials like FLORALI, pitting HFNC vs BiPAP, tend to not find an advantage for the NIPPV arm. While this rationale makes sense, it should be noted that the study does not directly investigate if this was the reason for the difference, and for what its worth the inverse argument that using driving pressure to reduce respiratory rate, hypercarbia, and work of breathing (other very common indications for intubation) would also theoretically reduce intubations. Furthermore, it's not clear why reducing P-SILI, which tends to cause mortality on a much longer duration, would improve the short-term outcome of need for intubation.
Bottom Line: This study demonstrated a benefit to CPAP over HFNC in terms of decreasing need for intubation amongst non-asthma/non-COPD patients with acute respiratory failure, and offered a physiologic rationale but one that requires further verification and discussion. While it may be reasonable to choose CPAP instead of HFNC in marginal patients at risk of intubation (but stable enough to trial noninvasive support first), in my opinion more studies are likely needed before a wholesale change in practice. The study also does not take into consideration the enhanced comfort and compliance we tend to see with HFNC over NIPPV, which should be considered as well.
For rural emergency departments, the decision to transfer a trauma patient to a level one center involves multiple factors including the patient’s hemodynamic stability. Harwell et al. looked at 47 trauma patients transferred from a rural hospital to a level one center. They found: “Overall mortality was significantly different between patients who had damage control laparotomy at a rural hospital (14.3%), were unstable transfer patients (75.0%), and stable transfer patients (3.3%; P < 0.001).” They concluded: “Rural damage control laparotomy may be used as a means of stabilization prior to transfer to a Level 1 center, and in appropriate patients may be life-saving.”
Preplanning with emergency medicine, surgery, radiology, anesthesia, nursing, and the receiving trauma center on how to manage these patients is critical.
Sport related concussion has been estimated to affect almost 2 million children and adolescents in the United states annually
Patients who take longer than four weeks to recover are considered to have persistent post concussive symptoms
This diagnosis is associated with poor educational, social and developmental outcomes in pediatric patients
Following sport related concussion, patients are recommended to have an individualized aerobic exercise program
Prior studies have found that sub symptom threshold aerobic exercise safely and significantly speeds recovery from sport related concussion.
Purpose: This study attempted to answer whether there is a direct relationship between adherence to a personalized exercise prescription and recovery or if initial symptom burden effects adherence to the prescription.
Design: Male and female adolescents aged 13 to 18 years old presenting within 10 days of injury and diagnosed with sport related concussion.
Almost all participants (94%) sustained concussion during interscholastic games or practices.
As it is known that physician encouragement can influence patient adherence to medical interventions, treating physicians in the study were blinded to study arm assignment.
Patients were given aerobic exercise prescriptions based on their heart rate threshold at the point of exercise intolerance on a graded treadmill test
Adherence to prescription was determined objectively with heart rate monitors. No participants exercised above their prescribed heart rate intensity.
Patients who completed at least 2/3 of their aerobic exercise prescription were considered to be adherent
Results: 61% of adolescents met the adherence criterion
Adherent patients were more symptomatic and were more exercise intolerant (worse initial exercise tolerance) at their initial visit.
These patients were also more adherent than those with fewer symptoms and with better exercise tolerance. This likely indicates a stronger motivation for those more symptomatic patients to engage in a potentially effective intervention.
Adherent patients recovered faster than those who were not adherent (median recovery time 12 days versus 21.5 days (P = 0.016)
Adherence during week one was inversely related to recovery time and to initial exercise tolerance but not to initial symptom severity
Conclusion: Adherence to individualized sub symptom threshold aerobic exercise within the first week of sport related concussion is associated with faster recovery. The initial degree of exercise intolerance (but not initial symptom severity) affects adherence to aerobic exercise prescription in an adolescent population with sport related concussion
The literature is not completely new regarding the use of intranasal dexmedetomidine for pediatric sedation, with several articles confirming noninferiority to benzodiazepines. It is a potent a2- adrenergic receptor agonist, which allows for sedation without analgesic properties. It can be considered for patients who are undergoing PAINLESS procedures. A recent article gave further clarification for dosing considerations when selecting this option. This study assessed varying weight-based doses and found the best effect with doses of 3 to 4 mcg/kg
Importantly, there is limited data that suggests this may result in longer discharge, duration of procedure and total time in the department compared to other sedation methods. Additionally, this option is not always readily available and approved for pediatric patients in every hospital.
Overall, Dexmedetomidine may be an excellent option for painless procedures, such as CT imaging or even MRI based on the literature, when available.
It's back to school season which means back to school injuries!
Scalp lacerations often require suturing or staple closure, but what if you can close the wound without any sharps that scare the kiddos? Consider using the Hair Apposition Technique (HAT)!
What is HAT?
- A very quick and easy technique for superficial scalp laceration closure made by twisting hair on each side of the laceration and sealing the twist with a small dot of glue for primary closure.
When do I consider HAT?
- For linear, superficial lacerations that are <10cm in length
- Laceration has achieved adequate hemostasis
- Patient has hair on both sides of the laceration
What are contraindications to HAT?
- Hair strands are less than 3cm in length
- Laceration is longer than 10cm in length
- Active bleeding from laceration despite hair apposition
- Significant wound tension
- Laceration is highly contaminated
How do I perform HAT?
- Debride wound as you normally wound for any laceration
- Take approximately 5 strands of hair on one side of the laceration and twist them together to make one twisted bundle
- Take approximately 5 strands of hair directly on the other side of the laceration and twist them together to make another twisted bundle
- Then take each bundle and intertwine the two bundles until the wound edges appose.
- Place a drop of glue on the twist
- Repeat along the length of the laceration until laceration is closed
Benefits of HAT:
- Based on a RCT from Singapore that compared suturing to HAT for superficial scalp lacerations that were <10cm, patient's were more satisfied, had less scaring, lower pain scores, shorter procedure tiems, adn less wound breakdown in the HAT group compared to the sutured group.
- A follow up study by the same group also assessed cost-effectievness of HAT compared to suturing (by taking into account staff time, need for staple/suture removal, treatment of complications, materials, etc) and found that HAT saved $28.50 USD when compared to suturing.
Modified hair apposition of scalp wounds- UpToDate
Bottom Line:
- Consider Hair Apposition Technique (HAT) for linear, superficial scalp lacerations, especially in pediatric patients as it is much more well tolerated (can also do this in adults!)
Pearls for the Patient in Cardiogenic Shock
In a study looking at 80 blunt trauma patients that died within 1 hour of arrival to a trauma center who underwent a noncontrast post mortem CT scan the following injuries were identified:
-40% traumatic brain injury
-25% long bone fracture
-22.5% hemoperitoneum
-25% cervical spine injury
- 18.8% moderate/large pneumothorax
-5% esophageal intubation
Blunt trauma arrest patients deserve decompression of the chest (preferred method is open with finger sweep). Intubation should be verified with end tidal CO2. Verification on arrival at the trauma center is also prudent.
Patient restraint is a high risk, high liability encounter for all levels of emergency medical practitioners. Often, acutely agitated patients benefit from de-escalation. This can be difficult to achieve in a resource limited setting. McDowell et al (2023) performed a comprehensive review of patient restraint encounters. Their work describes risk factors linked to adverse outcomes. Specifically, highly agitated patients who are physically and chemically restrained can experience clinical deterioration. The review also highlighted risks to EMS clinicians as well such as: needle stick, physical inury, and downstream litigation.
Bottom line:
Patient restraint represents a high risk encounter.
The authors of this paper suggest the following changes, supported by evidence, to the management of traumatic cardiac arrest:
1. Epinephrine, bicarbonate and calcium have limited if no role in traumatic cardiac arrest.
2. CPR may be harmful in traumatic cardiac arrest. Hypovolemia is the cause of death for most trauma patients and CPR cannot correct this.
3. Blood is the resuscitative fluid to be given and all other fluids do not have a role in traumatic cardiac arrest.
4. Correct hypoxia immediately.
5. Finger thoracostomy to decompress penumothoracies, not needles.
6. Utilize termination of resuscitation protocols to end resuscitations in the field.
29 yo baseball pitcher presents with right medial elbow pain. He felt a painful “pop” and could not continue to throw (due to loss of speed and control). Also notes mild paresthesias in 4th and 5th digits.
Ulnar collateral ligament (UCL) injury
Sprain of the UCL of the elbow can occur either as an acute injury or as the result of chronic excessive valgus stress due to throwing. This injury is seen in javelin throwers and baseball pitchers. Most recently, Angels superstar Shohei Ohtani suffered a torn UCL.
While traditionally this injury pattern was thought to occur in older, high-level pitchers (high velocity throwing), we are increasingly seeing this in younger athletes.
The repeated valgus stress of pitching leads to micro tearing and inflammation of the ligament. Over time, this leads to scarring and calcification and then ligament rupture.
This injury is more likely to happen in pitchers who “open up too soon” in their throwing motion. Fatigue related changes seen first in leg and core mechanics cause pitchers to open up earlier, increasing stress to the shoulder and the UCL of the elbow. Other risk factors include high velocity pitching, insufficient recovery time, and chronic overuse. The importance of proper pitching mechanics is very important as players whose pitching motion produces greater elbow valgus loads and shoulder external rotation torque are at increased risk for UCL tears.
Approximately one half of the torque generated during a fastball pitch is transmitted to the UCL. Well developed muscles about the elbow can dissipate enough energy that acute tearing is rare.
The athlete with a UCL sprain will complain of medial elbow pain that increases during the acceleration phase of throwing.
On examination, there is localized tenderness directly over the UCL:
http://www.texasshouldersurgeon.com/uploads/6/3/5/8/63580047/1446137856.png
Stress testing of the UCL causes both pain and demonstrates laxity.
Moving Valgus Stress Test:
Place elbow in the “90/90” position. Apply a valgus stress while ranging elbow through full arc of flexion and extension. A positive test will reproduce apprehension, pain or instability at the UCL origin between 70 and 120 degrees.
https://www.youtube.com/watch?v=OnkkHpG3Dqg&ab_channel=RussHoff
In this small propensity matching study looking at prehospital blood transfusion vs. emergency department blood transfusion in trauma patients aged 0-17 these authors found a better 24 and in-hospital mortality for patients who received prehospital blood transfusion compared to those receiving blood on arrival to the emergency department.
“The number needed to transfuse in the prehospital setting to save 1 child's life was 5 (95% CI, 3-10).”
Settings: Single ICU in Poland, randomized trial
Participants: intubated patients who needed arterial catheter placement. Patients who had adequate access to one axillary and one femoral artery were eligible.
Patients were randomized 1:1 for axillary or femoral artery cannulation.
Outcome measurement: Primary outcome was cannulation success rate. Secondary outcomes were first pass success rate, number of attempts.
Study Results:
Discussion:
Conclusion:
Ultrasound-guided cannulation of the axillary artery via the infraclavicular route is non-inferior to the cannulation of the common femoral artery. When cannulation of the radial or femoral artery is not available, we can consider axillary artery via the infraclavicular approach.
Splenic injury treatment depends on the grade of injury. In general, grades 1 and 2 are non-operatively managed. Grades 4 and 5 tend to be managed operatively. Interventional radiology is used commonly for grade 3 and grades 1 and 2 if active contrast extravasation is seen. Below is a refresher on splenic injury grading.
Table 1
Adaptation of AAST Organ Injury Scale for Spleen
| Grade | Injury type | Description of injury |
|---|---|---|
| I | Hematoma | Subcapsular, <10% surface area |
| II | Hematoma | Subcapsular, 10% to 50% surface area |
| Laceration | Capsular tear, 1 cm to 3 cm parenchymal depth that does not involve a trabecular vessel | |
| III | Hematoma | Subcapsular, >50% surface are or expanding: ruptured subcapsular or parenchymal hematoma: intraparenchymal hematoma_>5 cm or expanding |
| IV | Laceration | Laceration involving segmental or hilar vessels producing major devascularization (>25% of spleen) |
| V | Laceration | Completely shattered spleen |
This was a retrospective study involving several hospitals in Italy. 135 patients who had drowned (the term used in the article) were included. 4.5% of patients died. Most drowning occurred in July and August. The most common comorbidity was epilepsy in about 10% of patients. Several patients were also witnessed to have trauma and syncope. Early resuscitation, either by bystanders or trained professionals, was paramount in survival.
Children who are conscious at presentation and have mild or no respiratory distress have the best prognosis. A well appearing child should be observed for 6-8 hours, given that 98% of children will present with symptoms within the first 7 hours. A chest xray is not indicated in the asymptomatic patient. Patients who are submerged greater than 25 minutes or without ROSC after 30 minutes have a poor prognosis.
Bottom line: Never swim alone and everyone should be trained in bystander CPR.
Bystander CPR increases out-of-hospital CPR survival and direction by 911 telecommunicators increases the frequency of bystander CPR. The majority of 911 centers use Medical Priority Dispatch System which walks 911 telecommunicators through a series of questions that give different instructions based on the caller's answers. Studies have shown out-of-hospital cardiac arrests are only recognized between 79-92% of the time and telecommunicator instructions for CPR can take between 176-285 seconds.
This study reviewed recorded 911 calls of patients who were found to be in cardiac arrest. Calls where the caller was not with the patient and confirmed overdoses were some of the call types that were excluded.
Out of 65 reviewed calls, 28% were not recognized during the actual call. When they were reviewed, 8/18 of the calls were deemed to be recognizable. Themes that were noted were: incomplete or delayed recognition assessment (ie uncertainty in breathing), communication gaps (callers were confused with instructions or questions), caller emotional distress, delayed repositioning for chest compressions, non essential questions and assessments, and caller refusal/hesitation or inability to act.
Bottom line: In addition to bystander CPR training, education on the process and questions involved in calling 911 could be helpful in an emergency.
Background:
There has been interest in vitamin C as an adjunctive therapy in patients with systemic inflammation and vasoplegia to reduce inflammation. While it was suggested that vitamin C may have some benefit (along with hydrocortisone and thiamine) in septic shock, the LOVIT trial showed possible harm from high-dose vitamin C administration in septic ICU patients. The VALENCIA trial sought to evaluate whether vitamin C could reduce the duration of vasopressor therapy in patients with moderate vasoplegic shock.
Study:
-double-blinded RCT at two tertiary centers, 71 patients (36 to placebo, 35 to vitamin C)
-adult patients with vasoplegic shock of any cause
-vasopressor requirement >10 μg/min of norepi after hypovolemia was excluded
-notable exclusion criteria: end-stage renal failure and expected survival <12 hrs
Results:
-65 pts with septic shock, 6 pts with non-infectious cause
-no significant difference in the duration of vasopressors between the treatment group (median, 44 h [95% CI, 37-54 hrs]) and the control group (55 hrs [95% CI, 33-66 hrs])
-also no statistically significant difference in the vasopressor dose at 12 hourly time points, ICU or 28-day mortality and ICU or hospital length of stay
Take-home points:
Small study that ultimately may be under-powered but did not show that vitamin C reduces vasopressor duration in moderate vasoplegic shock
In recent years, there has been an uptick in non-operative management of acute appendicitis. This study examins outcomes in older patients (>65 years old).
The study authors evaluated retrospective data and included 474845 patients in the US with acute uncomplicated appendicitis betwen 10/2021 and 04/2022. All participants survived at least 24 hours postoperatively and none carried a diagnosis of inflammatory bowel disease; there were 43,846 patients treated nonoperatively and 430,999 who underwent appendectomy. The primary outcome was incidence of post-treatment complications, with secondary outcomes of mortality, length of stay, and inpatient costs.
In patients 65+, there was a 3.72% decrease in risk of complications, 1.82% increase in mortality, and increased LOS and costs.
Ultimately, operative management of acute appendicits was associated with reduced mortality, length of stay, and costs across all adult patients. While nonoperative management remains an option in the treatment of acute appendicits, surgical management continues to be the accepted standard.
The WHO and the US Department of Health and Human Services, among other groups, recommend between 150-300 minutes of moderate intensity or 75 to 150 minutes of vigorous intensity physical activity per week.
This could add up to almost 45 minutes a day!
Who has the time for that?
This is an extremely challenging goal with work and other life responsibilities.
Some recent studies asked whether routinely cramming the recommended weeks’ worth of physical activity into a couple of days, weekend warriors (WW), leads to the same life-extending benefits as distributing the exercise load throughout the week.
In a retrospective analysis of almost 90,000 individuals (56% women), providing a week of accelerometer-based physical activity data: Three activity patterns were compared: active weekend warrior (active WW, ≥150 minutes with ≥50% of total achieved in 1-2 days), active regular (≥150 minutes and not meeting active WW status), and inactive (<150 minutes).
A weekend warrior (WW) pattern of physical activity was associated with similarly lower risks of cardiovascular outcomes (incident atrial fibrillation, myocardial infarction, heart failure, and stroke) compared with more evenly distributed physical activity.
Another large prospective cohort study of over 350,000 US adults (51% women) did not find any significant difference in mortality rates between weekend warriors and regularly active participants. Compared with physically inactive participants, active participants (both weekend warrior and regularly active) had lower all-cause and cause-specific mortality rates.
Take home: Any exercise is better than none. Adults who perform 150 minutes or more of moderate to vigorous physical activity (or 75 minutes of vigorous activity) per week may experience similar health benefits whether the sessions are spread throughout the week or concentrated in a weekend.
Note: Being a weekend warrior can increase the risk of MSK complications and injury..
Future studies should include the use of wearable devices and not rely on self-reporting exercise behavior.
