UMEM Educational Pearls

Title: Think FAST Utility of Focused Assessment with Sonography for Trauma in Pediatrics

Category: Pediatrics

Keywords: pediatric trauma, ultrasound, FAST (PubMed Search)

Posted: 7/1/2022 by Rachel Wiltjer, DO (Updated: 11/12/2024)
Click here to contact Rachel Wiltjer, DO

 

  • Use of FAST is less common in pediatric trauma than in adult trauma
  • FAST in pediatric trauma has a lower negative predictive value than in adults
    • 1/3 of pediatric patients with hemoperitoneum on CT will have a negative FAST
    • Lowest sensitivity and specificity is in the under 2 years age group
  • A 2017 randomized clinical trial of ~900 patients showed no difference in clinical care, use of resources, or length of stay in hemodynamically stable children who received FAST + standard trauma evaluation versus standard trauma evaluation alone
  • There may be a role for FAST as a screening in patients with low suspicion for intraabdominal injury in conjunction with labs and physical exam, but this has not been fully explored

Bottom line: A positive FAST warrants further workup and may be helpful in the hemodynamically unstable pediatric trauma patient, but a negative FAST does not exclude intraabdominal injury and evidence for performing FAST in hemodynamically stable pediatric patients is limited.

 

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Title: Dodging DKA Dogma with Subcutaneous Insulin

Category: Critical Care

Keywords: Insulin infusion, diabetes mellitus, diabetic ketoacidosis, DKA, subcutaneous, long-acting (PubMed Search)

Posted: 6/29/2022 by Kami Windsor, MD (Updated: 9/21/2022)
Click here to contact Kami Windsor, MD

 

Background: It is classically taught that the tenets of DKA management are IV fluids, electrolyte repletion, and an insulin infusion that is titrated until approximately 2 hours after anion gap closure, when long-acting subcutaneous insulin is administered if the patient is tolerating oral intake. It has been previously found that earlier administration of subcutaneous long-acting insulin can shorten the time to anion gap closure, while other small studies have noted similar efficacy in subcutaneous insulin compared to IV in mild/moderate DKA. 

A recent JAMA article presents a retrospective evaluation of a prospectively-implemented DKA protocol (see "Full In-Depth" section) utilizing weight-based subcutaneous glargine and lispro, rather than IV regular insulin, as part of initial and ongoing floor-level inpatient treatment.

When compared to the period before the DKA protocol: 

  • ICU admissions decreased (27.9% from 67.8%, p<0.001)
  • There was no difference in overall amount of insulin and time to anion gap closure
  • There was no difference in 30-day mortality
  • There was no difference in incidence of hypoglycemc events.

The only exclusion criteria were age <18 years, pregnancy, and presence of other condition that required ICU admission. 

Bottom Line: Not all DKA requires IV insulin infusion.

At the very least, we should probably be utilizing early appropriate-dose subcutaneous long-acting insulin. With ongoing ICU bed shortages and the importance of decreasing unnecessary resource use and hospital costs, perhaps we should also be incorporating subcutaneous insulin protocols in our hospitals as well.

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Title: Wrist drop

Category: Orthopedics

Keywords: Radial nerve compression, peripheral nerve injury, wrist drop (PubMed Search)

Posted: 6/25/2022 by Brian Corwell, MD (Updated: 11/12/2024)
Click here to contact Brian Corwell, MD

The radial nerve is susceptible to compressive neuropathy against the spiral grove of the humerus which can lead to neuropraxia.

When the upper arm is compressed against a chair back or bar edge sometimes from a lost battle with alcohol:  Saturday night palsy.

When another individual sleeps on someone’s arm overnight compressing the radial nerve:  Honeymoon palsy

From nerve compression from improper technique with crutches:  Crutch palsy

If diagnosis not clear from history, DDx includes other entities that can also present with isolated wrist, thumb/finger drop

Horses:  Radial verve palsy, CVA, C7 compression

  • Most central disorders that cause arm weakness affect extensor muscles to a greater degree than the flexors.

Zebras:  Lead toxicity, acute porphyrias (often polyneuropathy but upper extremity before lower and frequently distal extensors

Careful history and exam important in differentiating

In cases of peripheral compression against the spital groove the triceps maintains strength.

The distal extensors lose strength (wrist and fingers)

Including the thumb abduction (abductor pollicis longus is radial-innervated)

AND so will the brachioradialis

The brachioradialis (despite being a forearm flexor) has dual innervation from the radial nerve in 80% of people.

Brachioradialis strength is often preserved in a central lesion.

            Best tested with arm supported on a surface in mid pronation/supination (hammer curl position) and have patient flex against resistance and evaluate muscle strength and bulk.

 

 



Title: Multimodal strategies for vasopressor administration

Category: Critical Care

Keywords: Vasopressors, Hypotension, Shock, Sepsis (PubMed Search)

Posted: 6/21/2022 by Mark Sutherland, MD (Updated: 11/12/2024)
Click here to contact Mark Sutherland, MD

Although it is well-documented that there is no true "maximum" dose of vasopressor medications, further blood pressure support as doses escalate to very high levels tends to be limited.  As such, debate has raged in Critical Care as to when is the "right" time to start a second vasoactive medication.  The VASST trial (Russell et al, NEJM, 2008) is considered to be the landmark trial in this area, and found a trend towards improvement with early addition of vasopressin to norepinephrine, but no statistically significant difference, and may have been underpowered.  

Partly as a result of VASST, the pendulum has tended to swing towards maximizing a single vasoactive before adding a second over the past decade.  The relatively high cost of vasopressin in the US has also driven this for many institutions.  However, more recently a "multi-modal" approach, emphasizing an earlier move to second, or even third, vasoactive medication, is increasingly popular.  Although cost is often prohibitive for angiotensin-2 given controversial benefits, many now advocate for targeting adrenergic receptors (e.g. with norepinephrine or epinephrine), vasopressin receptors (e.g. with vasopressin or terlipressin) and the RAAS system (e.g. with angiotensin 2) simultaneously in patients with refractory shock.  A recent review by Wieruszewski and Khanna in Critical Care (see references) outlines this approach well. 

Bottom Line: When to add a second vasoactive medication (e.g. vasopressin) for patients with refractory shock after a first vasoactive is controversial and not known.  Current practice is trending towards earlier addition of a second (or third) agent, especially if targeting different receptors, but there is limited high-quality evidence to support this approach.  Many practicioners (including this author) still follow VASST and consider vasopressin once doses of around 5-15 micrograms/min (non-weight based) of norepinephrine are reached.

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Title: What is the ideal length of treatment for pediatric community acquired pneumonia?

Category: Pediatrics

Keywords: PNA, pediatrics, duration of treatment (PubMed Search)

Posted: 6/17/2022 by Jenny Guyther, MD (Updated: 11/12/2024)
Click here to contact Jenny Guyther, MD

This was a randomized placebo controlled trial looking at 380 pediatric patients aged 6 months to 5 years who were diagnosed with nonsevere CAP and who showed early clinical improvement.  On day 6, one patient group was switched to a placebo while the other group continued with the antibiotics.
 
In this small study population, 5 days of a penicillin based antibiotic had a similar clinical response and antibiotic associated adverse effect profile compared to a 10 day course.  A 5 day course also reduced antibiotic exposure resistance compared to a 10 day course.  

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Vasopressor Tips in the Critically Ill

  • Critically ill patients often require the administration of vasopressors to maintain adequate organ perfusion.
  • A few tips to consider when administering vasopressors include:
    • Titrate to mean arterial blood pressure (MAP) or diastolic blood pressure goals.  Systolic blood pressure (SBP) is not a key driver of perfusion pressure.
    • As vasopressors also result in venoconstriction and can increase venous return, early initation may limit the need for overly aggressive fluid resuscitation.
    • Vasopressors can be safely administered through an appropriately placed peripheral venous catheter.
    • There is no maximal dose of vasopressors.
    • Consider vasopressors with a different mechanism of action in patients with persistent shock refractory to the initial vasopressor agent.

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Title: Head Impact Exposure and Concussion Incidence

Category: Airway Management

Keywords: Concussion, risk, head impact (PubMed Search)

Posted: 6/11/2022 by Brian Corwell, MD (Updated: 11/12/2024)
Click here to contact Brian Corwell, MD

Head Impact Exposure and Concussion Incidence

 

There has been a major focus on head impact biomechanics as a cause of single-impact concussion in football.

The role of repeated subclinical (without diagnosed concussion) head impact exposure (HIE)

during the preseason and regular season may also be contributory.

There may exist individualized concussion tolerance levels. This threshold may be reduced by the burden of sustained subconcussive impacts

NCAA Division 1 football athletes sustain a median of 426 impacts over the course of a football season

            652 impacts/season in high school football

Total head impact exposure during the preseason occurred at 2x the rate of the regular season

This association was investigated over 1120 athlete seasons from 6 NCAA D1 football programs across 5 years

Head Impact Telemetry was used to record head impact exposure

Elevated preseason HIE was strongly associated with preseason and in season concussion incidence

Total season HIE was strongly associated with total season concussion incidence.

Conclusion: There is a prolonged effect of HIE on concussion risk starting with preseason football.

Athletes with higher preseason HIE may have higher risk of concussion for the entire fall season.

In Practice

In 2016, the Ivy League eliminated full contact practices from the regular season in addition to their existing limits on the amount of full contact in practice during the spring and preseason.

Currently, the NCAA has the following limitations:  Teams won’t be allowed to hold full-contact practices on more than two days in a row. Each practice session is limited to only 75 minutes of full contact, in addition to a limit of two preseason scrimmages.

 

 

 

 

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Enthusiasm for early transfusion of blood products in patients with traumatic shock has increased with increasing availability of pre-hospital blood and plasma and results of studies such as the PAMPer trial of pre-hospital plasma have shown potential mortality benefits.  The deployment of prehospital blood for patients in hemorrhagic shock is promising but has significant cost and logistical considerations.

The RePHILL trial was a UK pre-hospital-based study of packed red blood cells and lyophilized plasma versus normal saline in trauma patients with presumed hemorrhagic shock.  Patients older than age 16 with an SBP<90 or an absent radial pulse were eligible to get up to 1L of the study intervention.  Multiple centers took part in the trial with 1:1 randomization stratified by study center.  The primary outcome was a combination of mortality or lactate clearance less than 20% per hour or both.

A total of 432 patients were assigned a study fluid. The population was 82% male, median of 38 years old, with 78% of injuries classified as blunt, and 82% of the presumed hemorrhage classified at non-compressible. This was a very ill population with an average SBP of 73, an average GCS of 7 and an ISS of 36. The average from emergency call to EMS arrival was 30 minutes, average to study intervention was 26 minutes and time from EMS activation to ED arrival was 90 minutes.

The results showed no difference in the primary composite endpoint (64% vs 65%), with no difference in mortality (43% vs 45%) or lactate clearance (50% vs 55%).  Interestingly, patients in the blood product arm had similar vital signs, lactate, and INR on ED arrival but received more blood products in the first 24 hours after ED arrival (pRBC 6.34 vs 4.41, p=0.004 and Plasma 5.04 vs 3.37, p=0.002). The was a trend toward improved early mortality at 3hr in the pre-hospital blood group (16% vs 22%, p=0.08).

Bottom Line(s):

Prehospital packed red blood cells and lyophilized plasma as compared to saline for traumatic shock did not improve mortality or lactate clearance in a well conducted multicenter RCT. 

The use of prehospital blood products is promising but population which benefits, and the optimal type of product and delivery mechanism remain unclear.

Increased blood utilization and lower early mortality in the blood product group may represent alteration in the spectrum of disease that requires different early management.

The reasons for this counterintuitive result are unclear and further trials of whole blood as well as fibrinogen concentrates are ongoing.

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Attitudes, Behavior, and Comfort of Emergency Medicine Residents in Caring for LGBT Patients: What Do We Know?

Background

This paper was written by some of the thought leaders in the Diversity, Equity and Inclusion realm in Emergency Medicine. Undergraduate medical education has minimal formal hours dedicated to LGBTQ+ health, and EM residency has even less. The authors wanted to assess EM resident comfort in caring for patients who identify as part of the LGBTQ+ community

Methodology

An anonymous service was sent out to CORD and was then disseminated to the residents of the 167 ACGME accredited EM residencies. It was a 24-question survey based on a similar one given to medical students. Overall, a total of 319 residents responded to the survey, with the vast majority identifying as heterosexual and cisgender

Results

The results seem at first to be contradictory. A majority of respondents (63.5%) were either comfortable or very comfortable in addressing the needs of LBGT patients. But when asked about specific behaviors related to providing care, there was more to the story. Only 17.3% of respondents always asked about sexual partner gender, 4.7% always asked about sexual orientation for an abdominal or genital complaint.

Perhaps more disturbing, the survey found that 10% of respondents had observed attending physicians make discriminatory or inappropriate comments about LGBT patients or staff, 2% of respondents were uncomfortable working alongside LGBT physicians, and 6% of respondents disagreed with the statement that LGBT patients deserve the same level of quality care as other patients.

Discussion

This study was published in 2019. Despite some amazing advancement in the LGBT community, we obviously still have a long way to go. This study shows the need for more formalized and routine education regarding LGBT population health issues at both the undergraduate and graduate medical education levels. It also demonstrates that LGBT physicians still experience discrimination in the workplace, even within our specialty. Be kind, be compassionate, be understanding.

 

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Small Bowel Obstruction

  • Although it takes about 11 minutes to diagnose SBO on ultrasound, newer studies have shown a decrease in sensitivity and specificity of SBO with 11 false negatives and 57 fall positives. So PLEASE BE CAREFUL when looking for SBO with ultrasound.
  • Let’s give a shout out to one of our medical students, Alexa Van Besien, who recently took some great images of a patient with a known SBO.

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Background:

Lung-protective ventilation with low-tidal volume improves outcome among patients with Acute Respiratory Distress Syndrome.  The use of low tidal volume ventilation in the Emergency Departments has been shown to provide early benefits for critically ill patients.

Methodology:

A systemic review and meta-analysis of studies comparing outcomes of patients receiving low tidal volume ventilation vs. those who did not receive low tidal volume ventilation.

The authors identified 11 studies with approximately 11000 patients.  The studies were mostly observational studies and there was no randomized trials.

The authors included 10 studies in the analysis, after excluding a single study that suggested Non-low tidal volume ventilation was associated with higher mortality than low tidal volume ventilation (1).

Results:

Comparing to those with NON-Low tidal volume ventilation in ED, patients with Low-Tidal volume ventilation in ED were associated with:

  • Significant lower risk of death (OR 0.80, 95% CI 0.72-0.88, I2 = 0%),
  • Lower risk of ARDS (OR 0.57, 95% CI 0.44-0.75, I2 = 21%),
  • Shorter ICU length of stay (Mean Difference -1.19 days [-2.38, -0.11]),
  • Shorter ventilator-free days (-1.03 days, [-1,74, -0.32]).

Discussion:

  • If the outlying study by Prekker et al was included, there as no significant difference in mortality.
  • Tidal volume in ED has been steadily decreased.  It was approximately 9 ml/kg of predicted body weight when reported in 2009, and was approximately 6.5 mg/kg PBW in 2018.
  • Most ventilator settings in the ED would be continued in the ICU.

Conclusion:

Although there was low quality of evidence for low tidal volume ventilation in the ED, Emergency clinicians should continue to consider this strategy.

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Title: Fifth Metacarpal Fracture

Category: Orthopedics

Keywords: Boxer, reduction (PubMed Search)

Posted: 5/28/2022 by Brian Corwell, MD (Updated: 11/12/2024)
Click here to contact Brian Corwell, MD

28-year-old male present with dorsal hand pain after “losing his temper”

On exam, you note dorsal swelling, tenderness, and deformity

AP, lateral and oblique views are obtained.

https://images.squarespace-cdn.com/content/v1/55d5e97fe4b0c4913b06a4dd/1440082762211-V6RW1TTWB1Q5C89TPIEC/boxers+2.jpg?format=500w

There is no rotational deformity but using the lateral view, you note that there is angulation

Measured as the shaft of the metacarpal as compared to the mid-point of the fracture fragment

Acceptable shaft angulation generally accepted to be less than 40°

Patient has greater that acceptable angulation so you have to perform closed reduction

After appropriate pain control consider the “90-90 method.” 

Flex the MCP, DIP, and PIP joints to 90 degrees.

This positioning stretches the MCP collateral ligaments helping to optimize reduction

Next, apply volar pressure over the dorsal aspect of the fracture site while applying pressure axially to the flexed PIP joint.

Best demonstrated below

https://www.youtube.com/watch?v=40irKoUJqsM

 

 



-If the patient is able to maintain mentation/airway/SpO2/hemodynamics and cough up blood, intubation is not immediately necessary

  • an ETT will actually reduce the diameter of the airway and can impede clearance and precipitate respiratory failure

-If you do intubate, intubate with the largest ETT possibly to faciliate bronchoscopic interventions and clearance of blood

  • Men: 8.5 or above; Women: 8.0 or above

-The CT scan that typically needs to be ordered is a CTA (not CTPA) with IV con

  • 90% of life-threatening hemoptysis from the bronchial arteries

-See if you can find prior/recent imaging in the immediate setting (e.g. pre-existing mass/cavitation on R/L/upper/lower lobes) 

  • having a level of suspicion for location/lateralization is helpful for the performing bronchoscopist to allow them to empirically occlude a location with an endobronchial blocker in a crashing hypoxemic patient if visualization is difficult 2/2 blood

-Get these meds ready before the bronchoscopist gets to the bedside to expedite care: 

  • iced/cold saline, thrombin, code-dose epi (which will be diluted)
  • there is also some (not great) data for intravenous TXA and improved outcomes

-If the pt's vent suddenly has new high peak pressures or decreased volumes after placement of endobronchial blocker, be concerned that the blocker has migrated

  • this can happen even with 1 cm movement of the ETT or blocker, or extension of the patient's neck
  • know where the ETT is secured as well as the endobronchial blocker (analagous to locking of a transvenous pacer)
  • pts with endobronchial blockers should also be on continuous neuromuscular blockade

 

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Encountered a situation in CCRU where we needed to prepare for a patient exsanguinating from gastric varices, and found a great summary of the different types of gastroesophageal balloons from EMRAP.

 

Summary: https://www.youtube.com/watch?v=Yv4muh0hX7Y

More in depth video on the Minnesota tube: https://www.youtube.com/watch?v=4FHIiA_doWU

Nice review article: https://www.sciencedirect.com/science/article/abs/pii/S0736467921009136



Aortic Dissection 

  • Ultrasound has a great specificity for aortic dissection. Remember to take a look at your aorta on all cardiac views.

  • Let’s give a shout out to Nikki Cali for diagnosing aortic dissection in a patient with a recent PE. Can you find the dissection flap in this image?

 

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Title: Post fracture pain management in children.

Category: Pediatrics

Keywords: motrin, narcotics, oxycodone, fracture care (PubMed Search)

Posted: 5/20/2022 by Jenny Guyther, MD (Updated: 11/12/2024)
Click here to contact Jenny Guyther, MD

This was a prospective study done in a pediatric emergency department where 329 children ages 4-16 years with isolated fractures were included.  After casting, children were prescribed either ibuprofen or oxycodone.  Pain score and activity level were followed by phone for 6 weeks.  The reduction in pain was comparable for motrin and oxycodone.  However, the children who received motrin experienced less side effects and quicker return to baseline activities compared to oxycodone.
Bottom line: Ibuprofen is a safe and effective option for fracture related pain and has fewer adverse effects compared to oxycodone.

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Peritonsillar Abscess 

 

  • Ultrasound can differentiate abscess vs cellulitis and has been shown to increase EP success of drainage as well as lower CT use. If you are concerned about complicated PTA with extension, use your clinical judgment.
  • Let’s give a shout out to Kelsey Johnson and Karl Dachroeden who successfully identified and drained a PTA at bedside as well as Taylor Miller who had a difficult case of phlegmon vs early abscess.

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Title: Blount's disease

Category: Orthopedics

Keywords: Varus, knee (PubMed Search)

Posted: 5/15/2022 by Brian Corwell, MD (Updated: 11/12/2024)
Click here to contact Brian Corwell, MD

4-year-old patient comes to the ED for an unrelated complaint and you notice that his knees appear to be touching while his ankles remain apart.

 

Genu Varum or “knock knees” may be caused by Infantile Blount’s disease

          -A progressive pathologic condition causing genu varum in children between ages 2 to 5

          - Centered at the tibia

          -Bilateral in up to 80%

          -More common in boys

          -Leg length discrepancy

          - Articular incongruity

Risk factors:  Early walkers (<1 year), overweight, large stature, Hispanic and African American

Results in disruption of normal cartilage growth at the MEDIAL aspect of the proximal tibia while LATERAL growth continues normally

May complain of knee soreness or subjective instability

On physical exam

          Focal angulation of the proximal tibia

Lateral thrust during stance phase of walking (brief lateral shift of proximal fibula and tibia)

          No tenderness or effusion

Imaging:   Plain film shows varus deformity of the proximal tibia with medial beaking (beak like appears of bone) and downward slope of the proximal tibia metaphysis (increased metaphyseal-diaphyseal angle)

 

https://paleyinstitute.org/wp-content/uploads/blounts1.jpg

Treatment depends upon the age of the child and the severity

  1. Medial unloader braces (should be started by age 3)

Successful in up to 80%

  1. Surgical correction (tibial osteotomy or growth plate arrest surgery)

Note: In adolescent variant bracing is ineffective and surgery is only treatment

          : Genu varum is normal in children <2 years old and becomes neutral at 14 months

 

DDX: Physiologic varus, Rickets

 

 

 



With the low supply of IV contrast for CT’s remember that you can use your friendly ultrasound to help you diagnose a wide range of pathology. Most often there is a HIGH SPECIFICITY (so if you see it, it is probably there but not a rule out test). Over the next week we will look at  5 cases where residents have diagnosed cool pathology using ultrasound. Just remember that with great power, comes great responsibility
 
 
 
 
 
 
 

 

Appendicitis

  • Ultrasound has a reported high specificity (97.9) for acute appendicitis in moderate to high pre-test probability of patients.

  • Let’s give a shout out to Reed Macy, who diagnosed appendicitis in a male with vomiting and abdominal pain! 

 



A recent prospective cohort study investigated the effect of low-dose droperidol on QTc in an emergency department:

  • 68 patients
  • Droperidol dose: median 1.875 mg (range: 0.625-2.5 mg)
  • Given as a 2-minute bolus
  • 94.1% received for headache management
  • Mean change in QTc: +29.9 ms (SD 15)
  • 17.6% (n=12) experienced QTc interval >=500 ms
  • 4.4% (n=3) had a change >=+60 ms
  • No serious arrhythmias or deaths
  • 13.2% (n=9) had at least one non-serious event (restlessness and/or anxiety)


Low-dose droperidol has a small effect on QTc and most patients remained below 500 ms.

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