Category: Critical Care
Keywords: CPR, Cardiac Arrest (PubMed Search)
Posted: 11/15/2016 by Rory Spiegel, MD
(Emailed: 10/31/2024)
Click here to contact Rory Spiegel, MD
It is well documented that when left to our own respiratory devices we will consistently over-ventilate patients presenting in cardiac arrest (1). A simple and effective method of preventing these overzealous tendencies is the utilization of a ventilator in place of a BVM. The ventilator is not typically used during cardiac arrest resuscitation because the high peak-pressures generated when chest compressions are being performed cause the ventilator to terminate the breath prior to the delivery of the intended tidal volume. This can easily be overcome by turning the peak-pressure alarm to its maximum setting. A number of studies have demonstrated the feasibility of this technique, most recently a cohort in published in Resuscitation by Chalkias et al (2). The 2010 European Resuscitation Council guidelines recommend a volume control mode at 6-7 mL/kg and 10 breaths/minute (3).
1. Aufderheide TP, Sigurdsson G, Pirrallo RG, Yannopoulos D, McKnite S, von Briesen C, Sparks CW, Conrad CJ, Provo TA, Lurie KG. Hyperventilation-induced hypotension during cardiopulmonary resusci- tation. Circulation. 2004;109:1960 –1965.
2. Chalkias, Athanasios et al. Airway pressure and outcome of out-of-hospital cardiac arrest: A prospective observational study. Resuscitation. November 2016
3. Deakin CD, Nolan JP, Soar J, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation 2010;81:1305–52.
Category: Toxicology
Posted: 9/5/2019 by Kathy Prybys, MD
(Emailed: 10/31/2024)
(Updated: 10/31/2024)
Click here to contact Kathy Prybys, MD
A 3 year old is bitten by a spider on his right ear which is causing him intense pain, tachycardia, and muscle cramping. Identify the spider. What is the treatment?
Category: Critical Care
Keywords: amikacin, Torsades de pointes, QT prolongation (PubMed Search)
Posted: 8/20/2019 by Quincy Tran, MD, PhD
(Emailed: 10/31/2024)
Click here to contact Quincy Tran, MD, PhD
Torsades de pointes and QT prolongation Associated with Antibiotics
Methods
The authors queried the United States FDA Adverse Event Reporting System (FAERS) from 01/01/2015 to 12/31/2017 for reports of Torsade de points/QT prolongation (TdP/QT).
Reporting Odd Ratio (ROR) was calculated as the ratio of the odds of reporting TdP/QTP versus all other ADRs for a given drug, compared with these reporting odds for all other drugs present in FAERS
Results
FAERS contained 2,042,801 reports from January 1, 2015 to December 31, 2017. There were 3,960 TdP/QTP reports from the study period (0.19%).
Macrolides ROR 14 (95% CI 11.8-17.38)
Linezolid ROR 12 (95% CI 8.5-18)
Amikacin ROR 11.8 (5.57-24.97)
Imipenem-cilastatin ROR 6.6 (3.13-13.9)
Fluoroquinolones ROR 5.68 (95% CI 4.78-6.76)
Limitations:
These adverse events are voluntary reports
There might be other confounded by concomitant drugs such as ondansetron, azole anti-fungals, antipsychotics.
Bottom Line:
This study confimed the previously-known antibiotics to be associated with Torsades de pointes and QT prolongation (Macrolides, Linezolid, Imipenem and Fluoroquinolones). However, this study found new association between amikacin and Torsades de pointes/QT prolongation.
Teng C, Walter EA, Gaspar DKS, Obodozie-Ofoegbu OO, Frei CR. Torsades de pointes and QT prolongation Associations with Antibiotics: A Pharmacovigilance Study of the FDA Adverse Event Reporting System. Int J Med Sci. 2019 Jun 10;16(7):1018-1022.
Category: Critical Care
Keywords: Botulism, IVDA (PubMed Search)
Posted: 7/2/2019 by Robert Brown, MD
(Emailed: 10/31/2024)
Click here to contact Robert Brown, MD
Don’t miss the injecting drug users with botulism!
Wound botulism presents as descending paralysis when Clostridium botulinum spores germinate in anaerobic necrotic tissue. There have been hundreds of cases in the last decade, but it is poorly reported outside of California.
Black tar heroin and subcutaneous injection (“skin popping”) carry the highest risk, but other injected drugs and other types of drug use suffice. C botulinum spores are viable unless cooked at or above 85°C for 5 minutes or longer and this is not achieved when cooking drugs.
Early administration of botulism anti-toxin (BAT) not only saves lives but can prevent paralysis and mechanical ventilation. An outbreak of 9 cases between September 2017 and April 2018 cost roughly $2.3 million, in part because patients didn’t present on average until 48 hours after symptom onset and it took an additional 2-4 days before the true cause of their respiratory depression and lethargy were understood. One patient died.
PEARL: talk to your injecting drug users about the symptoms of botulism: muscle weakness, difficulty swallowing, blurred vision, drooping eyelids, slurred speech, loss of facial expression, descending paralysis, and difficulty breathing. Consider botulism early in your patients who inject drugs but who do not respond to naloxone or who exhibit prolonged symptoms. Testing at the health department is performed with mouse antibodies to Botulism Neurotoxin (BoNT) combined with the patient’s serum.
Peak CM, Rosen H, Kamali A, et al. Wound Botulism Outbreak Among Persons Who Use Black Tar Heroin – San Diego County, California. MMWR. January 4, 2019; 67(5152):1415-1418.
Category: Critical Care
Keywords: Alarm Fatigue (PubMed Search)
Posted: 5/20/2019 by Robert Brown, MD
(Emailed: 10/31/2024)
(Updated: 10/31/2024)
Click here to contact Robert Brown, MD
In a study of alarms from 77 monitored ICU beds over the course of a month at the University of California, San Francisco, false alarms were common. Accellerated Ventircular Rhythms (AVRs) made up roughly one third of the alarms, and of the more than 4,361 AVRs, 94.9% were false while the remaining 5.1% did not result in a clinical action.
While this study had a majority of patients in the Med/Surg ICUs, a minority were from the cardiac and neurologic ICUs giving it some broad applicability. This study adds to the literature indicating there are subsets of alarms which may not be necessary or which may require adjustment to increase specificity.
Suba S, Sandoval CS, Zegre-Hemsey J, et al. Contribution of Electrocardiographic Accelerated Ventricular Rhythm Alarms to Alarm Fatigue. American Journal of Critical Care. 2019; 28(3):222-229
Suba S, Sandoval CS, Zegre-Hemsey J, et al. Contribution of Electrocardiographic Accelerated Ventricular Rhythm Alarms to Alarm Fatigue. American Journal of Critical Care. 2019; 28(3):222-229
Category: Visual Diagnosis
Posted: 10/5/2018 by Michael Bond, MD
(Emailed: 10/31/2024)
(Updated: 10/31/2024)
Click here to contact Michael Bond, MD
33 y/o M with PMH of ETOH induced pancreatitis presents with epigastic/RUQ pain & N/V after drinking last night, per patient his usual “pancreas pain”. The nurse shows you his blood tubes because they look “milky”. Lipase 1200, Ca 6.8.
What lab test would you add?
Answer: triglyceride level.
This patient has hypertriglyceridemia induced acure pancreatitis. His triglyceride level was 3047 mg/dL (normal value <150), HDL 20 mg/dL (normal value 40-60), total cholesterol 276 mg/dL (normal <200).
Treatment includes starting the patient on insulin drip, as insulin decreases serum triglyceride levels. If the glucose is <200 mg/dL the patient needs to started on dextrose 5% infusion. Apheresis can be considered if the patients triglyceride levels do not come down with insulin infusion (normally down without 3-4 days). Goal is a triglyceride level <500.
Category: Orthopedics
Posted: 10/1/2017 by Brian Corwell, MD
(Emailed: 10/31/2024)
(Updated: 10/31/2024)
Click here to contact Brian Corwell, MD
Category: Orthopedics
Posted: 10/1/2017 by Brian Corwell, MD
(Emailed: 10/31/2024)
(Updated: 10/31/2024)
Click here to contact Brian Corwell, MD
Category: Critical Care
Keywords: lung protective ventilation, ARDS (PubMed Search)
Posted: 3/21/2017 by Rory Spiegel, MD
(Emailed: 10/31/2024)
Click here to contact Rory Spiegel, MD
While lung protective ventilatory strategies have long been accepted as vital to the management of patients undergoing mechanical ventilation, the translation of such practices to the Emergency Department is still limited and inconsistent.
Fuller et al employed a protocol ensuring lung-protective tidal volumes, appropriate setting of positive end-expiratory pressure, rapid weaning of FiO2, and elevating the head-of-bed. The authors found that the number of patients who had lung protective strategies employed in the Emergency Department increased from 46.0% to 76.7%. This increase in protective strategies was associated with a 7.1% decrease in the rate of pulmonary complications (ARDS and VACs), 14.5% vs 7.4%, and a 14.3% decrease in in-hospital mortality, 34.1% vs 19.6%.
Fuller BM, Ferguson IT, Mohr NM, et al. Lung-Protective Ventilation Initiated in the Emergency Department (LOV-ED): A Quasi-Experimental, Before-After Trial. Ann Emerg Med. 2017;
Category: Critical Care
Keywords: peri-Intubation, shock index (PubMed Search)
Posted: 2/7/2017 by Rory Spiegel, MD
(Emailed: 10/31/2024)
Click here to contact Rory Spiegel, MD
Identifying patients at risk of hypotension during intubation is not always straight forward. The prevalence of peri-intubation hypotension in the Emergency Department has been demonstrated to be approximately 20%.1 And while certain variables increase the likelihood of peri-intubation hypotension (ex. Shock index> 0.80), no single factor predicts it accurately enough to be used at the bedside.2 In the majority of patients undergoing intubation, clinicians should be prepared for peri-intubation hypotension with either vasopressor infusions or push dose pressors.
1. Heffner AC, Swords D, Kline JA, Jones AE. The frequency and significance of postintubation hypotension during emergency airway management. J Crit Care. 2012;27(4):417.e9-13.
2. Heffner AC, Swords DS, Nussbaum ML, Kline JA, Jones AE. Predictors of the complication of postintubation hypotension during emergency airway management. J Crit Care. 2012;27(6):587-93.
Category: Critical Care
Posted: 4/12/2013 by Haney Mallemat, MD
(Emailed: 10/31/2024)
(Updated: 10/31/2024)
Click here to contact Haney Mallemat, MD
Adrenal insufficiency (AI) can be a life-threating condition and is classified as primary (failure of the adrenal gland) or secondary (failure of hypothalamic- pituitary axis).
Common causes of primary adrenal insufficiency include autoimmune destruction, infectious causes (TB and CMV), or interactions with drugs (e.g., anti-fungals, Etomidate, etc.). Secondary causes are usually due to abrupt withdrawal of steroids after chronic use, although sepsis and diseases of the hypothalamus or pituitary (e.g., CVA) may occur.
Signs and symptoms include fatigue, weakness, skin pigmentation, dizziness, abdominal pain, and orthostatic hypotension; it should be suspected with any of the following: hyponatremia, hyperkalemia, hypoglycemia, hypercalcemia, low free-cortisol level, and hemodynamic instability despite resuscitation.
Treatment:
• Correct underlying the disorder
• Resuscitation and hemodynamic support
• Correct hypoglycemia and electrolyte abnormalities
• Treat with hydrocortisone, cortisone, prednisone, or dexamethasone +/- fludrocortisone (Note: dexamethasone is attractive choice in the ED because it will not interfere with ACTH stimulation test)
Neary, N and Nieman, L. Adrenal Insufficiency: Etiology, diagnosis and treatment. Curr Opin Endocrinol Diabetes Obes. 2010 Jun;17(3):217-23.
Category: Airway Management
Keywords: RSI, Preoxygenation (PubMed Search)
Posted: 9/13/2016 by Rory Spiegel, MD
(Emailed: 10/31/2024)
Click here to contact Rory Spiegel, MD
During rapid sequence intubation (RSI) we endeavor to avoid positive pressure ventilation, prior to securing a definitive airway. As such, an adequate buffer of oxygen is necessary to ensure a safe apneic period. This process involves replacing the residual nitrogen in the lung with oxygen. It has been demonstrated that a standard nonrebreather (NRB) mask alone does not provide a high enough fractional concentration of oxygen (FiO2) to optimally denitrogenate the lungs (1). Even when a nasal cannula at 15L/min is utilized in addition to the NRB, the resulting FiO2 is not ideal. A bag-valve mask (BVM) with a one-way-valve or PEEP valve has been demonstrated to provide oxygen concentrations close to that of an anesthesia circuit. But its effectiveness is drastically reduced if a proper mask seal is not maintained during the entire pre-oxygenation period (1). This is not always logistically possible in the chaos of an Emergency Department intubation.
A standard NRB with the addition of flush-rate oxygen appears to be a viable alternative. Recently published in Annals of Emergency Medicine, Driver et al demonstrated that a NRB with wall oxygen flow rates increased to maximum levels, rather than the standard 15L/min, provided end-tidal O2 (ET-O2) levels similar to an anesthesia circuit (2).
1. Hayes-bradley C, Lewis A, Burns B, Miller M. Efficacy of Nasal Cannula Oxygen as a Preoxygenation Adjunct in Emergency Airway Management. Ann Emerg Med. 2016;68(2):174-80.
2. Driver BE, Prekker ME, Kornas RL, Cales EK, Reardon RF. Flush Rate Oxygen for Emergency Airway Preoxygenation. Ann Emerg Med. 2016;
Category: Toxicology
Keywords: opioids, toxicology (PubMed Search)
Posted: 11/20/2014 by Fermin Barrueto
(Emailed: 10/31/2024)
(Updated: 10/31/2024)
Click here to contact Fermin Barrueto
The pattern of prescription drug abuse continues to center around semisynthetic opioids like oxycodone and hydrocodone. Federal regulations have now raised hydrocodone to a schedule II drug like oxycodone. Despite efforts, the slope for natural and semisynthetic opioids remains steep. The ED measures of education, limit prescriptions for acute pain, minimize number of days/pills prescribed and utlize the prescription drug monitoring program are some basics that can assist you in better prescribing habits.
NCHS Data Brief, Number 166, September 2014
Category: Toxicology
Keywords: opioids, toxicology (PubMed Search)
Posted: 11/20/2014 by Fermin Barrueto
(Emailed: 10/31/2024)
(Updated: 10/31/2024)
Click here to contact Fermin Barrueto
The pattern of prescription drug abuse continues to center around semisynthetic opioids like oxycodone and hydrocodone. Federal regulations have now raised hydrocodone to a schedule II drug like oxycodone. Despite efforts, the slope for natural and semisynthetic opioids remains steep. The ED measures of education, limit prescriptions for acute pain, minimize number of days/pills prescribed and utlize the prescription drug monitoring program are some basics that can assist you in better prescribing habits.
NCHS Data Brief, Number 166, September 2014
Category: Toxicology
Keywords: Valproic acid (PubMed Search)
Posted: 10/16/2014 by Hong Kim, MD
(Emailed: 10/31/2024)
Click here to contact Hong Kim, MD
Valproic acid (VPA) is often used to treat seizure disorder and mania as a mood stabilizer. The mechanism of action involves enhancing GABA effect by preventing its degradation and slows the recovery from inactivation of neuronal Na+ channels (blockade effect).
VPA normally undergoes beta-oxidation (same as fatty acid metabolism) in the liver mitochondria, where VPA is transported into the mitochondria by carnitine shuttle pathway.
In setting of an overdose, carnitine is depleted and VPA undergoes omega-oxidation in the cytosol, resulting in a toxic metabolite.
Elevation NH3 occurs as the toxic metabolite inhibits the carbomyl phosphate synthase I, preventing the incorporation of NH3 into the urea cycle.
Signs and symptoms of acute toxicity include:
Laboratory abnormalities
Treatment: L-carnitine
Goldfrank's Toxicologic Emergencies 9th ed. p 705
Category: Pediatrics
Keywords: non-accidental trauma, clavicle fracture, neonate, pediatrics, abuse (PubMed Search)
Posted: 10/4/2014 by Ashley Strobel, MD
(Emailed: 10/31/2024)
Click here to contact Ashley Strobel, MD
Q: What is wrong with this baby? And what Dx should you entertain?
Previously healthy 7d old presents after difficulty feeding, one episode of vomiting and now with intermittent apneic episodes.
Non-accidental trauma (NAT) is most prevalent in children 0-3 months of age.
Radiographically classic metaphyseal lesions, rib fractures, and multiple fractures in various stages of healing are most commonly described in child abuse cases.
How do we know this is not just birth trauma from a shoulder dystocia, LGA (large for gestational age), or difficult vaginal delivery?
The key is dating the fracture. In this recent publication by Walters MM et al, prior to 8 days of life, 100% of radiographs did NOT have callus present. Callus formation is highly unlikely in fractures less than 9 days old, and typically appears by 15 days old. Callus thickness decreases inversely with fracture age. Additionally, subperiosteal new bone formation is highly unlikely in fractures less than 7 days old and typically appears by 10 days old. Subperiosteal new bone formation increases in thickness inversely with fracture age. Therefore, a clavicle fracture in a 7 day old without subperiosteal new bone formation or callus is unlikely from birth trauma and NAT should be considered.
How can you tell if subperiosteal new bone formation is present?
Subperiosteal new bone formation appears as a hazy cortical margin or a thin layer of bone separated from the original cortex by a discrete lucent interval. The new bone increases in thickness with time and may evolve to appear as a lamellated or multilayered linear hyperdensity parallel to the cortex of the bone. See referenced article for great picture examples.
NAT Work-up:
CT head without contrast if ≤2 yo
Skeletal Survey if ≤ 2 yo
AST, ALT, amylase, lipase, CBC, Manual Differential, BMP, UA, Urine Toxicology
Consults: Ophthalmology, Social Work, Child Protection
OH BUTT TUBE (Dark Green Top Sodium Heparin) for further inpatient team studies
ALTE Work-up:
Guided by history, however consider the following:
Full sepsis evaluation for neonate <30 days
ECG
Possible reflux or seizure evaluation
Consider NAT or Pertussis/RSV with cyanosis
It is controversial to send these infants home from the ED. Typically they benefit from 24 hours of monitoring, but this is a pearl for another day.
See article for further pictures of subperiosteal new bone formation:
Walters MM, Forbes PW, Buonomo C, and Kleinman PK. Healing Patterns of Clavicular Birth Injuries as a guide to fracture dating in cases of possible infant abuse. Pediatric Radiology. October 2014; 44: 1224-1229.
@AstrobelMD
1410041359_Clavicle_Fracture.jpg (1,743 Kb)
Category: Neurology
Keywords: Stroke, EMS, prehospital care, tPA, emergency medical services, fibrinolysis (PubMed Search)
Posted: 5/15/2014 by Ben Lawner, MS, DO
(Emailed: 10/31/2024)
(Updated: 7/3/2014)
Click here to contact Ben Lawner, MS, DO
The Prehospital Acute Neurological Treatment and Optimization of Medical Care in Stroke Study (PHANTOM-S) was a randomized prehospital clinical trial. On certain days, a dedicated Stroke Emergency Mobile (STEMO) responded to possible ischemic stroke incidents. Outcomes measured included time to thrombolysis and adverse events such as intracerebral hemorrhage. As opposed to usual prehospital care, a STEMO ambulance was equipped with a CT scanner, point of care laboratory, and a neurologist. According to the study, STEMO use resulted in reduced time to treatment (tPA) without adverse events.
Though this trial did not specifically measure clinical endpoints, it addresses issues central to the delivery of specialized prehospital care:
1) Are there certain conditions which might warrant a tailored, super-specialized EMS response?
2) Are EMS systems capable of delivering definitive care to the patient as opposed to delivering the patient to definitive care?
Stateside study has already started. The Houston Fire Department, in partnership with UTHeath, has already loosed a "Mobile Stroke Unit" on the streets. Like the STEMO, the specialized ambulance will be University hospital based, carry a neurologist, and have the capability to administer tPA.
STEMO pictures courtesy of the "NeuroEMS Blog"
http://www.neuroems.com/2014/05/14/tpa-in-the-truck-results-of-the-phantom-s-trial/
Ebinger M, Winter B, Wendt, M, et al. Effect of the use of ambulance based thrombolysis on time to thrombolysis in acute ischemic stroke. A randomized clinical trial. JAMA. 2014;311(16):1622-1631
Lake, D. "UTHeath introduces nation's first mobile stroke unit." Available at:https://www.uth.edu/media/story.htm?id=b1485cfc-110f-4a4c-91ea-06b573b3ba6d. Accessed on May 15, 2014
Category: Visual Diagnosis
Posted: 4/7/2014 by Haney Mallemat, MD
(Emailed: 10/31/2024)
(Updated: 10/31/2024)
Click here to contact Haney Mallemat, MD
23 year-old female presents complaining of progressive right lower quadrant pain after doing "vigorous" pushups. CT abdomen/pelvis below. What’s the diagnosis? (Hint: it’s not appendicitis)
Answer: Rectus sheath hematoma
Rectus Sheath Hematoma (RSH)
Rectus muscle tear causing damage to the superior or inferior epigastric arteries with subsequent bleeding into the rectus sheath; uncommon cause of abdominal pain but mimics almost any abdominal condition.
May occur spontaneously, but suspect with the following risk factors:
Typically a self-limiting condition, but hypovolemic shock may result from significant hematoma expansion.
Category: Orthopedics
Keywords: Sports Hernia, groin pain (PubMed Search)
Posted: 4/6/2014 by Brian Corwell, MD
(Emailed: 10/31/2024)
Click here to contact Brian Corwell, MD
Sports Hernia/Athletic pubalgia
Hx: Gradually increasing lower abdominal/proximal adductor pain. Usually activity related, resolves with rest. Frequent return despite rest when sports activity resumes.
Most common in athletes who perform cutting/maneuvers in addition to frequent acceleration/deceleration. Think ice hockey and soccer.
Bilateral symptoms not uncommon.
PE: Resisted sit up with palpation of the inferolateral edge of the distal rectus may recreate symptoms. Similarly, resisted hip adduction may elicit symptoms.
If for no other reason than to make the diagnosis harder to make, valsalva induced pain may also occur.
Fluoroscopic guided injections can be helpful to isolate the site of pain generation.
First line therapy is rest, non-narcotic analgesia and physical therapy.
With surgery, >80% return to pre injury level of play.
http://atlantasportsmedicine.com/orthopedic-surgeon/wp-content/uploads/2009/11/groin-injuries.jpg
Sports Hernia/Athletic Pubalgia: Evaluation and Management. Christopher Larson. Sports Health.
Category: International EM
Keywords: International, Chikungunya, vector-borne, (PubMed Search)
Posted: 3/5/2014 by Andrea Tenner, MD
(Emailed: 10/31/2024)
Click here to contact Andrea Tenner, MD
Case Presentation:
53 yo male presents with fever, myalgia, maculopapular rash, and severe polyarthralgia. He just returned from a cruise to the Caribbean islands.
Clinical Question:
What is the diagnosis?
Answer:
Chikungunya Virus
Bottom Line:
University of Maryland Section of Global Emergency Health
Author: Veronica Pei, MD