Category: Pharmacology & Therapeutics
Keywords: MIS-C, COVID (PubMed Search)
Posted: 2/7/2022 by Wesley Oliver
(Updated: 11/12/2024)
Click here to contact Wesley Oliver
Background:
Multisystem inflammatory syndrome in children (MIS-C) as defined by CDC Health Advisory in May 2020 is:
1) An individual aged <21 years presenting with fever*, laboratory evidence of inflammation**, and evidence of clinically severe illness requiring hospitalization, with multisystem (>2) organ involvement (cardiac, renal, respiratory, hematologic, gastrointestinal, dermatologic or neurological); AND
2) No alternative plausible diagnoses; AND
3) Positive for current or recent SARS-CoV-2 infection by RT-PCR, serology, or antigen test; or exposure to a suspected or confirmed COVID-19 case within the 4 weeks prior to the onset of symptoms.
*Fever >38.0°C for ≥24 hours, or report of subjective fever lasting ≥24 hours
**Including, but not limited to, one or more of the following: an elevated C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen, procalcitonin, d-dimer, ferritin, lactic acid dehydrogenase (LDH), or interleukin 6 (IL-6), elevated neutrophils, reduced lymphocytes and low albumin
As of January 31st, 2022 the CDC reports the following statistics related to MIS-C in the United States:
· Total MIS-C patients meeting case definition= 6,851
· Total MIS-C deaths meeting case definition = 59
· The median age of patients with MIS-C was 9 years. Half of children with MIS-C were between the ages of 5 and 13 years.
· 59% of the reported patients with race/ethnicity information available occurred in children who are Hispanic/Latino (1,746 patients) or Black, Non-Hispanic (2,050 patients).
· 98% of patients had a positive test result for SARS CoV-2, the virus that causes COVID-19. The remaining 2% of patients had contact with someone with COVID-19.
· 60% of reported patients were male.
Management:
First-Line Treatment:
· IVIG 2 g/kg dosed based on ideal body weight with a maximum of 100 grams (1000 mL)
o For patients with significant myocardial dysfunction and concern for fluid overload, the infusion can be given in divided doses over 2 days (1g/kg q12 x 2 doses)
PLUS
· Methylprednisolone 1 mg/kg (max of 30 mg/dose) IV twice daily and switch to PO and taper when clinically appropriate
Upon Consultation with Pediatric Hematology/Cardiology will consider adding the following therapies to IVIG and steroids:
· Enoxaparin treatment versus prophylactic dosing depending on D-dimer elevation and whether or not being admitted to PICU
· Aspirin 3-5 mg/kg (max 81 mg/dose) daily unless platelet count < 80 K/mcl
Second-Line Treatment (refractory to IVIG defined by symptoms and fever persisting >36 hours)*:
· Methylprednisolone pulse dosing- 30 mg/kg (max of 1000 mg/dose) x 3-5 days
OR
· High dose anakinra
OR
· Infliximab 5-10 mg/kg IV x1
*All second-line treatment options require peds infectious diseases and PICU attending approval
UMMS COVID/MIS-C Pathway: https://intra.umms.org/-/media/intranets/umms/pdfs/dept/pharmacy-and-therapeutics/guidelines/umms-pediatric-covid-pathway.pdf?upd=20220125144550
References:
1. Belhadjer Z, Meot M, Bajolle F, et al. Acute heart failure in multisystem inflammatory syndrome in children (MIS-C) in the context of global SARS-CoV-2 pandemic external icon. Circulation 2020.
2. Riphagen S, Gomez X, Gonzalez-Martinez C, Wilkinson N, Theocharis P. Hyperinflammatory shock in children during COVID-19 pandemic external icon. Lancet 2020.
3. Verdoni L, Mazza A, Gervasoni A, et al. An outbreak of severe Kawasaki-like disease at the Italian epicentre of the SARS-CoV-2 epidemic: an observational cohort study external icon. Lancet 2020.
4. CDC COVID Data Tracker: Health Department-Reported Cases of Multisystem Inflammatory Syndrome in Children (MIS-C) in the United States. https://covid.cdc.gov/covid-data-tracker/#mis-national-surveillance. February 1, 2022.
5. Henderson LA, Canna SW, Friedman KG, et al. American College of Rheumatology Clinical Guidance for Multisystem Inflammatory Syndrome in Children Associated With SARS–CoV-2 and Hyperinflammation in Pediatric COVID-19: Version 3. Arthritis and Rheumatology 2022.
Category: Pediatrics
Keywords: bell's palsy, pediatric malignancy (PubMed Search)
Posted: 2/4/2022 by Rachel Wiltjer, DO
Click here to contact Rachel Wiltjer, DO
Acute facial palsy is common in children and while bell’s palsy is significant proportion, there are other more concerning etiologies that make up a number of cases. A retrospective cohort study of pediatric patients with an ED diagnosis of Bell’s palsy was done using the Pediatric Health Information System and showed an incidence of 0.3% (0.03% in control) for new diagnosis of malignancy within the 60 days following the visit at which bell’s palsy was diagnosed. Younger age increased the risk. There was also a subset of patient’s excluded for diagnosis of bell’s palsy as well as malignancy at the index visit.
These numbers are small but may be clinically significant. They likely do not warrant laboratory or imaging workup as a rule but do make a case for detailed history taking and thorough exam. Consider avoiding steroids which are used commonly but lack high quality data and may undermine later efforts at tissue diagnosis of malignancy or even worsen prognosis.
Walsh PS, Gray JM, Ramgopal S, Lipshaw MJ. Risk of malignancy following emergency department Bell's palsy diagnosis in children. Am J Emerg Med. 2021 Dec 29;53:63-67.
Category: Critical Care
Posted: 1/27/2022 by William Teeter, MD
Click here to contact William Teeter, MD
A prospective, randomized, open-label, parallel assignment, single-center clinical trial performed by an anesthesiology-based Airway Team under emergent circumstances at UT Southwestern.
801 critically ill patients requiring emergency intubation were randomly assigned 1:1 at the time of intubation using standard RSI doses of etomidate and ketamine.
Primary endpoint: 7-day survival, was statistically and clinically significantly lower in the etomidate group compared with ketamine 77.3% (90/396) vs 85.1% (59/395); NNH = 13.
Secondary endpoints: 28-day survival rate was not statistically or clinically different for etomidate vs ketamine groups was no longer statistically different: 64.1% (142/396) vs 66.8% (131/395). Duration of mechanical ventilation, ICU LOS, use and duration of vasopressor, daily SOFA for 96 hours, adrenal insufficiency not significant.
Other considerations:
1. Similar to a 2009 study, ketamine group had lower blood pressure after RSI, but was not statistically significant. 2
2. Etomidate inhibits 11-beta hydroxylase in the adrenals. Associated with positive ACTH test and high SOFA scores, but not increased mortality.2
3. Ketamine raises ICP… just kidding.
Etomidate versus ketamine for emergency endotracheal intubation: a randomized clinical trial. Intensive Care Med. 2021 Dec 14. doi: 10.1007/s00134-021-06577-x. Online ahead of print.
Jabre P, Combes X, Lapostolle F, et al.; KETASED Collaborative Study Group. Etomidate versus ketamine for rapid sequence intubation in acutely ill patients: a multicentre randomised controlled trial. Lancet. 2009 Jul 25;374(9686):293-300. doi: 10.1016/S0140-6736(09)60949-1. Epub 2009 Jul 1. PMID: 19573904.
Bruder EA, Ball IM, Ridi S, Pickett W, Hohl C (2015) Single induction dose of etomidate versus other induction agents for endotracheal intubation in critically ill patients. Cochrane Database Syst Rev 1(1):CD010225. https://doi.org/10.1002/1ecweccccccccccc4651858.CD010225.pub2
Wang, X., Ding, X., Tong, Y. et al. Ketamine does not increase intracranial pressure compared with opioids: meta-analysis of randomized controlled trials. J Anesth 28, 821–827 (2014). https://doi.org/10.1007/s00540-014-1845-3
Category: Orthopedics
Keywords: Quadriceps contusion, immobilization, hematoma (PubMed Search)
Posted: 1/23/2022 by Brian Corwell, MD
(Updated: 11/12/2024)
Click here to contact Brian Corwell, MD
Quadriceps contusion
Mechanism: Blunt trauma from ball, helmet, stick
Usually to the central region
Damage to highly vascular area of the muscle and to local blood vessels can cause hematoma formation
Typical trauma history and pain worse with muscle activation (knee flexion)
Physical exam: Bruising, tenderness, palpable mass/hematoma
Goals of care: Minimize intramuscular bleeding
Treatment: NSAIDS, crutches, unique type of immobilization
Attempt to increase resting length of the quadriceps muscle to facilitate early healing and return to function
Note: Left untreated, large contusions may result in myositis ossificans
Category: Pediatrics
Keywords: pediatrics, COVID, vaccination, hospitalization (PubMed Search)
Posted: 1/21/2022 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD
Woodruff RC, Campbell AP, Taylor CA, et al. Risk Factors for Severe COVID-19 in Children. Pediatrics. 2022;149(1):e2021053418.
Category: Critical Care
Posted: 1/18/2022 by Duyen Tran, MD
Click here to contact Duyen Tran, MD
Clinical pearls for hypothermic cardiac arrest
Paal P, Gordon L, Strapazzon G et al. Accidental hypothermia–an update. Scand J Trauma Resusc Emerg Med. 2016;24(1). doi:10.1186/s13049-016-0303-7
Pasquier M, Rousson V, Darocha T et al. Hypothermia outcome prediction after extracorporeal life support for hypothermic cardiac arrest patients: An external validation of the HOPE score. Resuscitation. 2019;139:321-328. doi:10.1016/j.resuscitation.2019.03.017
Misch M, Helman A. Accidental Hypothermia and Cardiac Arrest | CritCases | EM Cases. Emergency Medicine Cases. http://emergencymedicinecases.com/accidental-hypothermia-cardiac-arrest. Published 2019. Accessed January 18, 2022.
Category: Critical Care
Keywords: trauma, pneumothorax, positive pressure ventilation, invasive mechanical ventilation, tension pneumothorax (PubMed Search)
Posted: 1/14/2022 by Kami Windsor, MD
Click here to contact Kami Windsor, MD
Background: Conventional medical wisdom long held that patients with pneumothorax (PTX) who require positive pressure ventilation (PPV) should undergo tube thoracostomy to prevent enlarging or tension pneumothorax, even if otherwise they would be managed expectantly.1
Bottom Line: The cardiopulmonar-ily stable patient with small PTX doesn’t need empiric tube thoracostomy simply because they’re receiving positive pressure ventilation. If you are unlucky enough to still have them in your ED at day 5 in these COVID times, provide closer monitoring as the observation failure rate may increase dramatically around this time.
Category: Toxicology
Keywords: flumazenil, benzodiazepine overdose, adverse events (PubMed Search)
Posted: 1/13/2022 by Hong Kim, MD
Click here to contact Hong Kim, MD
Flumazenil is a reversal agent for benzodiazepine overdose. Adverse events including seizure, agitation and cardiac arrhythmias have been reported but the frequency of adverse events is unknown.
AE and serious AEs were defined as:
AE:
Serious AE (SAE):
A systematic review/meta-analyses of 13 randomized controlled trials showed
Most common AEs
Most common SAEs
Conclusion
PENNINGA E ET AL.Adverse Events Associated with Flumazenil Treatment for the Management of Suspected Benzodiazepine Intoxication--A Systematic Review with Meta-Analyses of Randomized Trials. Basic Clin Pharmacol Toxicol. 2016
DOI: 10.1111/bcpt.12434
Category: Orthopedics
Keywords: hamstring, strain, muscle tear (PubMed Search)
Posted: 1/8/2022 by Brian Corwell, MD
Click here to contact Brian Corwell, MD
Hamstring Injury
Prevalence varies by sport ranging from 8 to 25 percent with a high recurrence rate frequently during the ensuing sport season, usually in next 2 months but may extend up to one year!
Highest in sports that involve rapid acceleration and deceleration
3 highest risk sports - football and men’s and women’s soccer
Average time lost 17-21 days
Injury much less common in younger athletes
The hamstring is composed of three muscles: the biceps femoris, semitendinosus, and semimembranosus.
Primarily involved in knee flexion and hip extension
Biceps femoris is most commonly injured
https://www.ncbi.nlm.nih.gov/books/NBK539862/figure/article-28873.image.f1
Simple grading system using 3 grades
Grade 1 – mild strain
Grade 2 – Partial tear
Grade 3 – Complete tear
Proximal injuries are more common than distal injuries, occurring at the musculotendinous junction
Avulsion fractures of the ischium occur rarely occur in adults but may occur in skeletally immature athletes
https://radiopaedia.org/cases/ischial-tuberosity-avulsion
When watching a sporting event you will see the athlete grab the buttock or upper thigh. They usually cannot return to play. Most grade 2 or 3 injuries will require crutches. If seeing them the following day significant bruising may be seen.
Numerous modifiable and non-modifiable risk factors have been identified including:
*Weakness of ipsilateral quadriceps or contralateral hamstring, hamstring, hip & quadriceps tightness/poor flexibility, poor warm-up, sudden increased training volume and muscle fatigue.
*Older age (risk increase may begin as early as age 23)
Prior hamstring injury (up to 6x increased risk)
**Premature return to sport increases the risk of reinjury
Differential Diagnosis: Lumbar radiculopathy, sciatic nerve irritation or compression, stress fracture of femur.
Refer to sports medicine/orthopedics for avulsion injuries, complete proximal complete tears and partial or complete distal tears
Category: Pediatrics
Keywords: foreign body, ear, insect, button battery (PubMed Search)
Posted: 1/7/2022 by Natasha Smith, MD
(Updated: 11/12/2024)
Click here to contact Natasha Smith, MD
Many types of foreign bodies may be found in a child's ear. Some examples include: beads, cotton swabs, food, insects, and button batteries.
Patients can be asymptomatic. However, they often have otalgia, pruritus, fullness, tinnitus, hearing loss, otorrhea, or bleeding. Obtain a history of the type of foreign body, when/how it entered the ear, and if there was a prior attempt at removal. Also ask if there are foreign bodies elsewhere, such as in the nose. Perform Rinne and Weber tests before and after removing the foreign body if the child is old enough to participate.
Delayed presentation can result in edema and otitis externa. When the foreign body is sharp, there may be damage to the tympanic membrane (TM) and ossicles.
Consult ENT when there is suspicion of damage to TM, when hearing loss is present, or when removal is especially challenging. Spherical foreign bodies are more difficult to remove.
Remove foreign body if it can be visualized. Wax curettes, right-angled hooks, alligator forceps, and Frazier tip suctions can facilitate removal. Avoid additional trauma due to concern for edema, bleeding, TM perforation, or distal displacement of the object. Anxiety in the child will lead to increased difficulty with removal.
A button battery in the ear is an emergency that can result in severe damage, including TM perforation, scarring or stenosis of the ear canal, and deeper injury. Seeds such as beans or peas and other absorptive material in the ear can expand, so do not irrigate when such foreign bodies are present. Living insects should be killed with alcohol, lidocaine, or mineral oil prior to performing foreign body removal.
After removal, reassess ear canal and TM. Some foreign bodies require removal in the operating room. If the object has been successfully removed, evaluate for otitis externa or iatrogenic injury to the ear canal, and prescribe antibiotic otic drops when needed. When TM has perforated, refer for formal audiogram. ENT follow up is recommended for all patients.
Butts, SC, Goldstein NA, Rosenfeld RM et al. Atlas of Pediatric Emergency Medicine: 3rd Edition. Binita Shah. Brooklyn, NY: McGraw Hill, 2019. 437-438. Print.
Category: Critical Care
Keywords: Calcium, Cardiac Arrest, ACLS, Code Blue (PubMed Search)
Posted: 1/5/2022 by Mark Sutherland, MD
Click here to contact Mark Sutherland, MD
There are several well known medications that we tend to give by default during cardiac arrests. It seems like for each of them, every few years someone does an RCT to see if they really help anybody, and we're all disappointed by what they find. Well... prepare to be disappointed again, I'm afraid.
These Danish authors randomized 391 patients in cardiac arrest to either calcium or saline (given IV or IO). They gave 2 doses of either calcium chloride or saline, with the first dose being along with the first epi dose. Primary outcome was ROSC. They also looked at modified Rankin at 30 and 90 days.
The trial was stopped early for harm. Now, we all know the dangers of interpreting studies that were stopped early, but this doesn't look great for calcium. 19% of the calcium group had ROSC compared to 27% of the saline group (p = 0.09). Percentage of patients alive, and with favorable mRS at 30 days also both favored the saline group (although also not statistically significantly). By the way, of the patients who had calcium levels sent, 74% in the calcium group, vs 2% in the saline group, were hypercalcemic. Whether that had anything to do with the outcome, we may never know.
Bottom Line: Is this saying that calcium hurts patients in cardiac arrest? Maybe... but I don't think this is high quality enough data to draw that conclusion. At the very least, however, just giving everyone in arrest calcium is probably not terribly helpful. If you have a reason to give it (known severe hypocalcemia, recent parathyroid surgery, suspected hyperkalemia, etc) then go for it, otherwise you can probably focus your resus on more important things.
Vallentin MF, Granfeldt A, Meilandt C, et al. Effect of Intravenous or Intraosseous Calcium vs Saline on Return of Spontaneous Circulation in Adults With Out-of-Hospital Cardiac Arrest: A Randomized Clinical Trial. JAMA. 2021;326(22):2268–2276. doi:10.1001/jama.2021.20929
Category: Pediatrics
Posted: 12/31/2021 by Rose Chasm, MD
Click here to contact Rose Chasm, MD
Benary, Lozano, Higley, Lowe. Pediatrics. Ondansteron Prescription is Associated with Reduced Return Visits to the Pediatric Emergency Department for Children with Gastroenteritis. 76,5. November 2020.
Rivera-Dominguez, Ward. StatPearls. Pediatric Gastroenteritis. April 2021.
Managing Acute Gastroenteritis Among Children. CDC. MMWR.
Category: Critical Care
Posted: 12/28/2021 by Mike Winters, MBA, MD
Click here to contact Mike Winters, MBA, MD
The BOUGIE Trial
Driver BE, et al. Effect of use of a bougie vs endotracheal tube with stylet on successful intubation on the first attempt among critically ill patients undergoing tracheal intubation. JAMA. 2021. Published online December 8, 2021
Category: Airway Management
Keywords: Caffeine, Exercise, VO2 max (PubMed Search)
Posted: 12/25/2021 by Brian Corwell, MD
Click here to contact Brian Corwell, MD
Caffeine is probably the most wildly used and studied drug/supplement in the world.
It has been shown to enhance exercise capacity and performance.
Mechanism of action is likely multifactorial and involves adenosine receptor antagonism via direct CNS action improving mental alertness, reaction time and reducing the perceived exertion rate (pain).
To no surprise, amateur and elite athletes use caffeine to improve performance.
The well-accepted dosage of caffeine to improve performance is between 3 and 6 mg/kg, approximately 60 min before exercise. This dosage promotes (between 1 and 8%) performance gains in aerobic exercises and exercises with high glycolytic demand from cyclists to tennis players to weightlifters.
Consider the lower end of this range if interested in trying this on your own.
In an evaluation of 20,686 urine samples of elite athletes, almost 75% of the samples contained caffeine in concentrations higher than 0.1 μg/mL
Caffeine also increases maximal oxygen uptake (VO2 max)
23 elite athletes were tested twice with and twice without caffeine.
Randomized, double-blinded, placebo-controlled study.
Caffeine 4.5 mg/kg taken 45 minutes before exercise
Measures: Time to exhaustion and VO2 max.
Caffeine increased time to exhaustion and VO2 max, thereby increasing overall performance.
If you are going to incorporate using caffeine before your next workout, I suggest espresso shots for extra caffeine without the volume of a large cup of coffee. Beware of known side effects such as jitters, anxiousness and difficulties with sleep if taken later in the day. Also consider stomach upset digestive issues, and increased heart rate.
Happy Holidays!!!!
Category: Toxicology
Keywords: xylazine, adulterate, heroin, fentanyl (PubMed Search)
Posted: 12/16/2021 by Hong Kim, MD
Click here to contact Hong Kim, MD
Xylazine is a central alpha-2 agonist (similar to clonidine) that is used as a veterinary tranquilizer. It also possesses analgesic, and muscle relaxant properties. Heroin/fentanyl is increasingly being adulterated with xylazine and resulting in severe adverse effects (CNS and respiratory depression, bradycardia, and hypotension), including deaths.
According to CDC, 0.1%-5.5% of IMF death in US between 2019 – 2020 involved xylazine.
In Philadelphia, PA:
The detection of xylazine in unintentional overdose death increased from
Approximately 25% of drug seizures in Philadelphia contained xylazine in 2019
There is no effective pharmacologic agent for xylazine toxicity. Similar to clonidine toxicity, high dose naloxone may be tried. But pediatric data show that approximately 50% of pediatric clonidine toxicity response to high-dose naloxone administration. Thus, naloxone administration may not reverse the CNS/respiratory depression, bradycardia and hypotension.
Conclusion
O’Donnell J, Tanz LJ, Gladden RM, Davis NL, Bitting J. Trends in and Characteristics of Drug Overdose Deaths Involving Illicitly Manufactured Fentanyls — United States, 2019–2020. MMWR Morb Mortal Wkly Rep 2021;70:1740-1746. DOI: http://dx.doi.org/10.15585/mmwr.mm7050e3external icon.
Johnson J, et al. Inj Prev 2021;27:395–398. doi:10.1136/injuryprev-2020-043968
Category: Critical Care
Keywords: bacterial infection, sepsis, Emergency Department, broad spectrum antibiotics (PubMed Search)
Posted: 12/14/2021 by Quincy Tran, MD, PhD
(Updated: 11/12/2024)
Click here to contact Quincy Tran, MD, PhD
When we initiate the sepsis bundle in the ED for patients with suspected sepsis, what probability that those patients who received broad spectrum antibiotics in the ED would have bacterial infection.
This study (Shappell et al) provides us with a glimpse of those number.
Settings: Retrospective study of adults presenting to 4 EDs in Massachusetts.
Patients: patients with suspected serious bacterial infection in ED, defined as blood cultures and initiation of at least one broad spectrum antibiotics. Random selection of 75 patients per hospital.
Patients were categorized in 4 groups:
Outcome: Prevalence of each category.
Study Results: 300 patients who received broad spectrum antibiotics.
3. For patients who were admitted to the ICU (P = 0.26)
a. Definite 16.5%
b. Likely 8.6%
c. Unlikely 16.4%
d. Definitely no 20.4%
4. Source of infection
Discussion:
Conclusion:
Approximately 30% of patients who had blood cultures drawn and received broad spectrum antibiotics in ED have low likelihood of bacterial infection.
Reference:
1. Shappell CN, Klompas M, Ochoa A, Rhee C; CDC Prevention Epicenters Program. Likelihood of Bacterial Infection in Patients Treated With Broad-Spectrum IV Antibiotics in the Emergency Department. Crit Care Med. 2021 Nov 1;49(11):e1144-e1150. doi: 10.1097/CCM.0000000000005090. PMID: 33967206; PMCID: PMC8516665.
2. Klein Klouwenberg PM, Cremer OL, van Vught LA, Ong DS, Frencken JF, Schultz MJ, Bonten MJ, van der Poll T. Likelihood of infection in patients with presumed sepsis at the time of intensive care unit admission: a cohort study. Crit Care. 2015 Sep 7;19(1):319. doi: 10.1186/s13054-015-1035-1. PMID: 26346055; PMCID: PMC4562354.
Category: Critical Care
Posted: 12/7/2021 by Caleb Chan, MD
Click here to contact Caleb Chan, MD
Clinical Pearls for Variceal Hemorrhage
-lower mortality with “restrictive” (Hgb 7-9 g/dL) rather than liberal strategy
-antibiotic “prophylaxis” reduces mortality
-no need to correct INR with FFP
-vasoactives (i.e. octreotide, somatostatin, terlipressin) alone may actually control bleeding
-for your ICU boarders...if persistent or severe rebleeding (despite endoscopic therapy), rescue TIPS is therapy of choice (call IR)
Zanetto A, Shalaby S, Feltracco P, et al. Recent advances in the management of acute variceal hemorrhage. Journal of Clinical Medicine. 2021;10(17):3818.
Category: Pharmacology & Therapeutics
Keywords: Calcium, cardiac arrest (PubMed Search)
Posted: 12/4/2021 by Ashley Martinelli
(Updated: 11/12/2024)
Click here to contact Ashley Martinelli
Calcium is commonly administered during cardiac arrest, but there is little data to support or refute its use. The Calcium for Out-of-Hospital Cardiac Arrest trial was a randomized, double-blind, placebo-controlled parallel group study conducted in Denmark. Their EMS system responds to all cardiac arrests with an ambulance and a physician-manned mobile emergency care unit.
Adult patients were included if they had out of-of-hospital (OOH) cardiac arrest and received at least 1 dose of epinephrine. Exclusion criteria were traumatic arrest, known or suspected pregnancy, prior enrollment in the trial, receipt of epinephrine from an EMS unit not in the trial, or a clinical indication for calcium during the arrest (i.e. hyperkalemia or hypocalcemia).
Patients received 735mg calcium chloride dihydrate (5 mmol CaCl –US standard product is 1000mg) or saline control immediately after the first dose of epinephrine. A second dose was administered after the second dose of epinephrine if cardiac arrest ongoing. Teams were blinded to the treatments. The primary outcome was ROSC for at least 20 minutes.
397 patients were randomized (197 calcium, 200 saline). The average age was 68 years old, 70% were male, and over 80% of the cardiac arrests occurred at home, 60% witnessed arrests, and 82% received bystander CPR. Only 25% were in a shockable rhythm. The time to first epinephrine and study drug was approximately 17 minutes and over 70% received two doses.
ROSC rates were low and not statistically different between groups, 19% in the calcium group vs 27% in the saline group. There was no difference in survival to 30d or neurologic function. In the patients who did achieve ROSC in the calcium arm, 74% had hypercalcemia.
Bottom Line: The routine use of calcium in out-of-hospital cardiac arrest is not recommended.
Vallentin MF, et al. Effect of intravenous or intraosseous calcium vs saline on return of spontaneous circulation in adults with out-of-hospital cardiac arrest. JAMA. Published online November 30, 2021. doi:10.1001/jama.2021.20929
Category: Pediatrics
Keywords: peds ortho, calcaneus, stress injury (PubMed Search)
Posted: 12/3/2021 by Rachel Wiltjer, DO
Click here to contact Rachel Wiltjer, DO
Sever Disease
Smith JM, Varacallo M. Sever Disease. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441928/
Category: Orthopedics
Keywords: Elbow, fracture, radiology (PubMed Search)
Posted: 11/27/2021 by Brian Corwell, MD
(Updated: 11/12/2024)
Click here to contact Brian Corwell, MD
Presentations of Fracture in Nursemaids Elbow
Study group: Visits by children younger than 10 years, with a diagnosis of radial head subluxation at 1 of 45 pediatric EDs from 2010 to 2018.
Retrospective cohort study of 88,466 ED visits for radial head subluxation
Outcome: Missed fracture (return visit for upper extremity fracture within 7 days of the index visit).
Results
Median patient age was 2.1 years,
59% of visits were by female patients,
60% of cases occurred in the left arm.
Radiography was performed at 28.5% of visits (Range 19.8% to 41.7%.)
Extremity fractures were observed in 247 cases, representing 0.3% of the cohort.
The odds of missed fracture were higher in:
Summary:
Only 0.3% of children with a diagnosis of radial head subluxation subsequently received a diagnosis of an upper extremity fracture within 7 days of the index visit.
Missed fractures were commonly about the elbow such as a supracondylar fracture. However, this study also found a significant proportion of missed fractures in other locations (e.g. shoulder, wrist), highlighting the importance of a careful physical examination, and the limitations of localizing pain in younger children.
Recurrence was common, and the risk of recurrence decreased with increasing age at first presentation. Overall, radial head subluxation recurrence was 8.7% after the first visit VERSUS 12%-13% in children younger than 2 years. THese patients are likely to return to the ED with a recurrence within 2 years. These findings should help inform anticipatory guidance to parents regarding the risk of recurrence based on their child’s age.