UMEM Educational Pearls

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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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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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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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%

2. 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

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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• Autism spectrum disorder and other neurodevelopmental disorders can predispose to challenging ED encounters secondary to difficulties with sensory processing and communication
• Small changes to the environment can help to reduce stress, generally by decreasing stimulation
• Use quieter areas of the ED when possible, decrease volume of alarms, and consider noise cancelling headphones or white noise if available
• Consider dimming the lights, turning the monitor/computer screen away from the patient
• Allow the patient to remain in their own clothing and consider whether restrictive items such as the monitor, pulse oximeter, and blood pressure cuff are necessary (but continue to use them when they are medically appropriate)
• Offering distraction via electronics, fidget toys, or weighted blanket (or lead apron) may help with managing stress
• Ask the patient or family which modifications would be helpful for the patient and ask child life for assistance where available

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Based on prior studies¹ indicating possibly improved outcomes with vasopressin and steroids in IHCA (Vasopressin, Steroids, and Epi, Oh my! A new cocktail for cardiac arrest?), the VAM-IHCA trial² compared the addition of both methylprednisolone and vasopressin to normal saline placebo, given with standard epinephrine resuscitation during in hospital cardiac arrest (IHCA).

The use of methylprednisolone plus vasopressin was associated with increased likelihood of ROSC: 42% intervention vs. 33% placebo, RR 1.3 (95% CI 1.03-1.63), risk difference 9.6% (95% CI 1.1-18.0%); p=0.03.

BUT there was no increased likelihood of favorable neurologic outcome (7.6% in both groups).

Recent publication on evaluation of long-term outcomes of the VAM-ICHA trial³ showed that, at 6-month and 1-year follow-up, there was no difference between groups in:

• Survival
• Favorable neurologic outcome (CPC 1 or 2; mRS 0-3)
• Health-related quality of life (per EQ-5D5L survey)

Bottom Line: Existing evidence does not currently support the use of methylprednisolone and vasopressin as routine code drugs for IHCA resuscitation. 

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9-year-old male left hand dominant, presents with left elbow pain.

 He is a future “star pitcher,” says his coach dad. “Doc, I bet you didn’t know that although only 10% of people throw with their left hand almost a 1/3^rd of MLB pitchers are lefties. He is 3x more likely than a righty to pitch in MLB.” “Maybe I’m asking him to throw too much.”

Hx: Lateral elbow pain and “stiffness” worse with activity that is better with rest

PE:  Lateral elbow tenderness (capitellum) with slight (approx. 20 degrees) decreased loss of extension. Minimal swelling noted.

Dx: Panner's disease refers to osteochondrosis of the capitellum (similar to Legg Calve Perthes). Likely due to AVN from repetitive trauma. May also be due to endocrine disturbances.

Affects the dominant elbow of boys between the ages of 5 and 10

Associated with the repetitive trauma of throwing or gymnastics.

Must be differentiated from osteochondrosis dissecans which occurs in the older child >13yo when the ossification of the capitellum is complete

Radiology: 

The articular surface of the capitellum may appear irregular or flattened with areas of radiolucency (43%). Loose bodies not seen with Panners, much more likely with OCD lesions.

Treatment:  Ice and NSAIDs. Avoid pitching/gymnastics etc. until full radiographic and clinical healing. If significant pain and/or swelling place patient in long arm posterior splint for 7-10 days. Resolution may take several months and up to one year.

ED Low-Tidal Volume Ventilation

• Low-tidal volume ventilation (LTVV) reduces mortality in patients with ARDS and may reduce mortality in patients without ARDS.
• Recent literature has highlighted the importance of initial ED ventilator settings, as these often persist for many hours after ICU admission.
• But..does the use of LTVV in the ED really make a difference?
• A recent systematic review and meta-analysis sought to evaluate the use of LTVV in the ED and the impact upon clinical outcomes.
• In short, the use of LTVV in the ED was associated with an increase in the use of LTVV in the ICU, decreased occurrence of ARDS after admission, shorter ICU and hospital lengths of stay, decreased duration of mechanical ventilation, and decreased mortality.
• Take Home Point:  The use of LTVV in the ED makes a difference!

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A recent study investigated the association between concussion and subsequent mental health conditions in a pediatric population.

Retrospective cohort study. Pediatric patients aged 5 to 18 years who presented to an ED, PCP or mental health practitioner from April 2010, to March 2020, in Ontario, Canada. 

Primary outcome: Time to first diagnosis with a mental health condition during follow-up

Secondary outcomes: 1) self-harm 2) psychiatric hospitalization 3) death by suicide.

Mental health conditions: anxiety and neurotic disorders, adjustment reactions, behavioral disorders, mood and eating disorders, schizophrenia, substance use disorder, suicidal ideation, and disorders of psychological development.

Study group, almost 450,000 patients. Age and sex matching between those with concussion and those who experienced an orthopedic injury. 

A significant association (P < .001) was found between concussion and mental health conditions

A significant association emerged between concussion and self-harm and psychiatric hospitalization 

No association with suicide

Conclusion: Concussion was significantly associated with risk of mental illness, psychiatric hospitalization and self-harm but not death by suicide.

Concussed patients had an almost 40% higher rate of mental health conditions compared to controls (adjusted hazard ratio 1.39)

Take home: Screen patients who return to the ED with post concussive symptoms for mental health symptoms/concerns and provide appropriate awareness for parents

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During the height of the pandemic, a large proportion of patients who were referred to our center for VV-ECMO evaluation were on Airway Pressure Release Ventilation (APRV).  Does this ventilation mode offer any advantage?  This new randomized control trial attempted to offer an answer.

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1.Settings: RCT, single center

2. Patients: 90 adults patients with respiratory failure due to COVID-19

3. Intervention: APRV with maximum allowed high pressure of 30 cm H20, at time of 4 seconds.  Low pressure was always 0 cm H20, and expiratory time (T-low) at 0.4-0.6 seconds. This T-low time can be adjusted upon analysis of flow-time curve at expiration.

4. Comparison: Low tidal volume (LTV)  strategy according to ARDSNet protocol.

5. Outcome: Primary outcome was Ventilator Free Days at 28 days.

6.Study Results:

• Baseline characteristics were similar. At randomization, PF ratio for APRV group = 140 (SD 42) vs. 149 (SD 50) for LTV group.
• Median Ventilator Free Day for APRV group: 3.7 [0-15] days vs. 5.2 [0-19] for LTV group ( P = 0.28)
• APRV group had higher PaO2/FiO2 ratio during first 7 days (mean difference = 26, P<0.001)
• ICU length of stay for APRV group: 9 [7-16] vs. 12 [8-17] days (P = 0.17)
• Severe hypercapnia (Pco2 at ≥ 55 along with a pH < 7.15): APRV group = 19 (42%) vs. LTV = 7 (15%), P = 0.009.
• Death at 28 days: 35 (78%) for APRV group, vs. 27 (60%) for LTV group ( P = 0.07)

7.Discussion:

• Hypercapnea was transient and was mostly due to implementation of the ventilator settings.  The protocol recommended reduction of T-high to allow more ventilation, but most clinicians did not want to shorten the T-High, but instead opted for higher T-low.
• Although the number of barotrauma were similar in both group, all 4 cases of barotrauma in the APRV group occurred within a very short period of time (3 weeks), prompted the safety monitoring board to recommend stopping recruitment for COVID-19 patients.

8.Conclusion:

APRV was not associated with more ventilator free days or other outcomes among patients with COVID-19, when compared to Low Tidal Volume strategies in this small RCT.

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Diphenhydramine (B) has historically been utilized in combination with haloperidol 5mg (5) and lorazepam 2mg (2) in the treatment of acute agitation.  The most common rationale for adding diphenhydramine is prevention of EPS, however literature to support this is lacking.  A recently published paper examined diphenhydramine/haloperidol/lorazepam combination (B52) vs haloperidol/lorazepam combination therapy (52) to compare the need for additional agitation treatments as a surrogate for clinical efficacy.

This retrospective, multicentered noninferiority study included 400 emergency medicine patients, 200 per treatment arm. On average, the patients were 40 years old, 64% male, and predominantly Caucasian.  More patients in the B52 group had psychiatric illness listed as their primary cause for agitation compared to the 52 group. The two most frequently reported substances on urine drug screens, if collected, were amphetamines (35%) and cannabinoid (35.5%).

Results:

-No difference in the use of additional agitation medications within 2 hours

-More patients in the 52 group were noted to receive anticholinergic medications within 2 days, but indications varied and were not associated with EPS treatment

The B52 combination was associated with:

---Increased length of stay 17 h (10-26) vs 13.8 h (9-12), p = 0.03

---Increased use of restraints 43% vs 26.5%, p = 0.001

---Hypotension 16% vs 3.5%, p <0.001

---Use of nasal canula oxygen 3% vs 0%, p < 0.01

The addition of diphenhydramine may not be necessary to prevent EPS in patients receiving haloperidol for agitation and is associated with increased length of stay and adverse events, likely due to its additive sedative properties. 

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• 2/3’s present in the neonatal period and can mimic conditions such as sepsis, gastroenteritis, and meningitis requiring careful consideration to prompt testing
• Common symptoms are poor feeding, lethargy, irritability, vomiting, and encephalopathy
• May be referred in if detected on newborn screen, but not all are tested on the newborn screen
• Should look on labs for acidosis, elevated anion gap, hyperammonemia, lactic acidosis, ketosis/ketonuria, and hyper/hypoglycemia  
• Emergent treatment includes: identification and treatment of any underlying triggers (such as infection), stopping any protein intake until situation can be clarified, providing fluids with glucose (requirements of 8-10 mg/kg/min of glucose in neonates), and genetics consultation

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The use of catecholamines following OHCA has been a mainstay option for management for decades. Epinephrine is the most commonly used drug for cardiovascular support, but norepinephrine and dobutamine are also used. There is relatively poor data in their use in the out of hospital cardiac arrest (OHCA). This observational multicenter trial in France enrolled 766 patients with persistent requirement for catecholamine infusion post ROSC for 6 hours despite adequate fluid resuscitation. 285 (37%) received epinephrine and 481 (63%) norepinephrine.

Findings

• Deaths from refractory shock (35% vs. 9%, P<0.001) and Recurrent cardiac arrest (9% vs. 3%, P<0.001) were higher in the epinephrine group
• In both univariate/multivariate analyses, use of epinephrine was significantly associated with:
  • All-cause mortality during the hospital stay (83% vs. 61%, P<0.001) / (OR 2.6, 95%CI 1.4–4.7, P=0.002)
  • Cardiovascular-specific mortality (44% vs. 11%, P<0.001) / (aOR 5.5, 95%CI 3.0–10.3, P<0.001)
  • Frequency of unfavorable neurological outcomes (37% vs. 15%, P<0.001) / (aOR 3.0, 95%CI 1.6–5.7, P=0.001)
• While propensity scoring and match analysis largely confirmed these findings, further regression did not associate epinephrine with all-cause mortality.

Limitations:

• Epinephrine arm: significantly longer time to ROSC, lower blood pH at admission, higher rates of unshockable rhythm, higher levels of arterial lactate at admission, lower LV ejection fraction, and higher levels of myocardial dysfunction.
• Propensity matching always has the potential for confounders.

Summary:

Norepinephrine may be a better choice for persistent post-arrest shock. However, this study is not designed to sufficiently address confounders to recommend abandoning epinephrine altogether, but it does give one pause. 

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