Category: Pediatrics
Posted: 12/4/2020 by Cathya Olivas Michels, MD
(Updated: 11/26/2024)
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Several studies have described factors associated with peri-intubation cardiac arrest in the adult population. Factors such as pre-intubation hypotension, elevated BMI, and elevated shock index (HR/SBP) have been associated with cardiac arrest following intubation in adult ED patients. Given the differences in anatomy and physiology in children, one may expect risk factors for peri-intubation cardiac arrest to differ in children.
A number of studies have examined factors associated with peri-intubation cardiac arrest in the pediatric population, but these have remained limited to the inpatient setting. These studies have found that, in hospitalized and PICU patients, the factors of hemodynamic instability, hypoxemia, history of difficult airway, pre-existing cardiac disease, and higher number of intubation attempts are associated with peri-intubation cardiac arrest. A paucity of literature exists on this airway complication in pediatric ED patients.
Pokrajac et al. provide the first study on risk factors for peri-intubation cardiac arrest in pediatric ED patients. These authors conducted a retrospective nested case-control study of pediatric patients (ages <18 years) who presented to a tertiary children’s hospital in San Diego from 2009-2017. Cases included patients who had a cardiac arrest within 20 minutes after the start of endotracheal intubation. Authors selected a number of predictors to examine, including age-adjusted hemodynamic variables, capillary refill, pulse oximetry, patient characteristics, intubation-related factors, and pre-intubation interventions.
The authors found the following:
- Demographic characteristics:
o Patients with peri-intubation cardiac arrest were significantly younger (<1 year of age), shorter, and more likely to have history of preexisting pulmonary disease.
- Incident characteristics:
o Patients with peri-intubation cardiac arrest were more likely to have:
-Low or unobtainable SBP or DBP
-Delayed capillary refill time
-Low (<92%) or unobtainable pre-intubation SpO2
-More than 1 intubation attempt than controls
-No paralytic or sedative agent prior to intubation
o Patients with peri-intubation cardiac arrest were NOT more likely to have increases in age-adjusted HR or pediatric shock index in comparison to controls.
o The strongest clinical predictor for peri-intubation cardiac arrest was pre-intubation hypoxia or unobtainable SpO2. This fact is supported by children’s increased metabolic rate and thus increased oxygen consumption. This physiologic finding explains the shorter amount of time it takes children to develop acute hypoxia, particularly in the peri-intubation setting.
Bottom line: If planning to intubate a pediatric patient in the ED, keep in mind that pre-intubation systolic or diastolic hypotension, delayed capillary refill time, multiple intubation attempts, and hypoxia in particular may increase the risk for peri-intubation cardiac arrest. Consider providing apneic oxygenation to minimize hypoxemia prior to intubation.
Heffner, A. C., Swords, D. S., Neale, M. N. & Jones, A. E. Incidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation 84, 1500–1504 (2013).
Hill, K. Cardiac Arrests Associated with Tracheal Intubations in PICUs: A Multicenter Cohort Study. The Journal of Emergency Medicine 51, 617–618 (2016).
Kim, W. Y. et al. Factors Associated with the Occurrence of Cardiac Arrest after Emergency Tracheal Intubation in the Emergency Department. PLoS ONE 9, e112779 (2014).
Pokrajac, N. et al. Risk Factors for Peri-intubation Cardiac Arrest in a Pediatric Emergency Department Pediatric Emergency Care Publish Ahead of Print, (2020).
Category: Toxicology
Keywords: ethanol exposure, infant, national poison data system. (PubMed Search)
Posted: 12/3/2020 by Hong Kim, MD
Click here to contact Hong Kim, MD
Ethanol exposure among young children can result in significant morbidity. Infants and young children can be exposed to ethanol in many different ways: exploratory ingestion, mixed in formula-both intentionally and unintentionally, etc.
A recently published study used national poison data system to characterize the ethanol exposure among infants < 12 months of age.
Results:
Between 2009-2018, 1,818 ethanol exposures among infants were reported. Oral ingestion was the most common (96.7%; n=1738). Annual number of ethanol exposure increased by 37.5% each year.
Exposure site
Age
Clinically significant effects
563 infants (31%) were evaluated at hospital
38% (n=214) of the exposures were hospitalized
0-5 months of age
Conclusion
Ethanol exposure among infants is increasing each year and associated with serious clinical effects.
Gaw CE et al. Beverage ethanol exposure among infants reported to United States pison control centers 2020 Clin Toxicol (Phila) https://doi.org/10.1080/15563650.2020.1843658
Category: Orthopedics
Keywords: Shoulder, biceps, tendon (PubMed Search)
Posted: 11/28/2020 by Brian Corwell, MD
(Updated: 11/26/2024)
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A 25 year old athlete presents to the ED with right anterior shoulder pain.
Pain radiates into proximal biceps.
It is worse with heavy lifting and especially “pulling” exercises at the gym.
How do we evaluate for biceps tendonitis?
Pathology is often the long head of the biceps
https://physioworks.com.au/wp-content/uploads/2019/12/biceps-tendonitis.jpg
Start by palpating this area and attempt to reproduce the discomfort
Speed’s test
Yergason’s test
Category: Pediatrics
Keywords: vaginitis, vaginal discharge (PubMed Search)
Posted: 11/20/2020 by Jenny Guyther, MD
(Updated: 11/26/2024)
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To determine if the child is prepubescent, look for the lack of pubic hair, clitoral size, configuration of the hymen, breast development, and axillary hair growth. A Tanner stage of 1 would be consistent with prepuberty.
The proper positioning for the physical exam will allow the child to be comfortable and the examiner to obtain an adequate view including up to one-third of the vagina.
If the child is small enough, they can lay in the parent’s lap. For a larger child, you can have the parent sit in the bed with the patient or stand near the child’s head. Engage child life if available.
The frog leg position with gentle downward and outward traction of the labia at the 5- and 7-o’clock positions provides the optimal view.
The knee to chest position is helpful when further evaluation is needed.
A rectovaginal exam is useful for evaluation of masses or foreign body only and is not routinely needed. Place the examiner’s little finger in the rectum and the other hand on the abdomen and palpate.
The use of a vaginal speculum is rarely needed in prepubertal children; if it is needed, perform the exam under anesthesia.
McCaskill A, Inabinet CF, Tomlin K, Burgis J. Prepubertal Genital Bleeding: Examination and Differential Diagnosis in Pediatric Female Patients. J Emerg Med. 2018 Oct;55(4):e97-e100. doi: 10.1016/j.jemermed.2018.07.
Loveless M, Myint O. Vulvovaginitis- presentation of more common problems in pediatric and adolescent gynecology. Best Pract Res Clin Obstet Gynaecol. 2018 Apr;48:14-27. doi: 10.1016/j.bpobgyn.2017.08.014. Epub 2017 Sep 5. PMID: 28927766.
Manning S. Genital Complaints at the Extremes of Age. Emerg Med Clin North Am. 2019 May;37(2):193-205. doi: 10.1016/j.emc.2019.01.003. PMID: 30940366.
Category: Critical Care
Keywords: vasopressor, peripheral IV, safety (PubMed Search)
Posted: 11/17/2020 by Quincy Tran, MD, PhD
(Updated: 11/26/2024)
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Summary
Our group performed a meta-analysis to assess whether it is safe to infuse vasopressor through peripheral venous catheters. We identified 9 studies with a total of 1835 patients. The prevalence of complications among the pooled patient population was 9%. Up to 96% of the complications was extravasation and almost no complications required any treatment.
A few studies reported safe infusion of norepinephrine up to 0.1 mcg/kg/min for up to 24 hours.
In exploratory meta-regression, catheter size 20 or larger was negatively associated with the rate of complications.
We also observed that studies that were published within the past 5 years reported significantly lower rate of complications from older studies. This suggested that with careful planning and monitoring, it is safe to start vasopressor through peripheral IV.
Limitation
most of the included studies were observational. No studies had enough power to statistically analyze any variables that could predict complications.
Bottom line: we should start vasopressor as soon as indicated, if we have good, reliable IV access.
Complication of vasopressor infusion through peripheral venous catheter: A systematic review and meta-analysis
Quincy K Tran, Gaurika Mester, Vera Bzhilyanskaya, Leenah Z Afridi, Sanketh Andhavarapu, Zain Alam, Austin Widjaja, Brooke Andersen, Ann Matta, Ali Pourmand.
Am J Emerg Med. 2020 Sep 28;S0735-6757(20)30842-1. doi: 10.1016/j.ajem.2020.09.047. Online ahead of print.
Category: Critical Care
Keywords: Hyponatremia (PubMed Search)
Posted: 11/12/2020 by Caleb Chan, MD
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Baek SH, Jo YH, Ahn S, et al. Risk of overcorrection in rapid intermittent bolus vs slow continuous infusion therapies of hypertonic saline for patients with symptomatic hyponatremia: the salsa randomized clinical trial. JAMA Intern Med. Published online October 26, 2020.
Category: Neurology
Keywords: migraine, headache, diagnosis, treatment, prevention (PubMed Search)
Posted: 11/11/2020 by WanTsu Wendy Chang, MD
(Updated: 11/13/2020)
Click here to contact WanTsu Wendy Chang, MD
Bottom Line: Migraine is a common and debilitating condition that benefits from early treatment. Consider initiating preventive therapy for patients who experience at least 2 migraine days per month and adverse effects despite treatment.
Follow me on Twitter @EM_NCC
Category: Pharmacology & Therapeutics
Keywords: Beta-Lactam, Allergies, Sepsis (PubMed Search)
Posted: 11/7/2020 by Wesley Oliver
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Komyathy KL, Judd WR, Ratliff PD, Hughes RE. Assessing mortality outcomes of beta-lactam-allergic patients presenting with sepsis. Am J Emerg Med. 2020;38(9): 1816-1819.
Category: Pediatrics
Keywords: pain management, ketamine (PubMed Search)
Posted: 11/6/2020 by Prianka Kandhal, MD
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Silva LOJ, Lee JY, Bellolio F, Homme JL, Anderson JL. Intranasal ketamine for acute pain management in children: A systematic review and meta-analysis. American Journal of Emergency Medicine. 2020 (38)1860-1866. doi: 10.1016/j.ajem.2020.05.094
Category: Toxicology
Keywords: mad honey poisoning (PubMed Search)
Posted: 11/5/2020 by Hong Kim, MD
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What is the cause of Mad honey poisoning?
Grayanotoxin
Grayanotoxin is a neurotoxin that is found in honey contaminated with nectar of Rhododendron plants. It binds to activated/open neuronal sodium channels and prevents inactivation of sodium channels. Case reports of mad honey poisoning is often reported in the eastern Black Sea region of Turkey. Commercial honey producers frequently mix honeys from multiple sources to decrease the grayanotoxin contamination.
Mad honey poisoning is rarely fatal and generally resolves within 24 hours. Commonly reported symptoms include dizziness, weakness, impaired consciousness/disorientation, excessive perspiration, nausea/vomiting, and paresthesia. In severe intoxication, patients can experience complete AV block, bradycardia/asystole, hypotension, and syncope.
Management is primarily supportive with atropine and IV fluids.
Category: Critical Care
Keywords: airway management, cardiac arrest, COVID-10, SARS-CoV-2, cardiopulmonary resuscitation, CPR (PubMed Search)
Posted: 11/3/2020 by Kami Windsor, MD
Click here to contact Kami Windsor, MD
As the number of COVID-19 cases rises worldwide, prehospital and emergency department healthcare workers remain at high risk of exposure and infection during CPR for patients with cardiac arrest and potential SARS-CoV-2.
Existing evidence supports similar cardiac arrest outcomes in airways managed with a supraglottic airway (SGA) compared to endotracheal intubation (ETT).1 It is generally accepted that the best airway seal is provided with endotracheal intubation + viral filter, but how well do SGAs prevent spread of aerosols?
In CPR simulation studies:
Category: Pediatrics
Posted: 10/31/2020 by Rose Chasm, MD
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The current COVID-19 pandemic and known aerosolized transmission has triggered many ED process changes, including the discouragement of utilizing nebulizers to administer inhaled bronchodilators such as albuterol for concern of spread. Historically, both patients and providers preferred the use of nebulizers as they are easier to use and the belief was that they were more effective than meterd dose inhalers. However, evidence based data has consistently shown that for both adult and pediatric patients that when MDI's are used WITH a spacer:
Albuterol: 2.5 mg nebulizer solution = 3-5 MDI puffs
Albuterol: 5 mg nebulizer solution = 5-10 MDI puffs
Ipratropium: 0.25 mg nebulizer solution = 2 MDI puffs
Ipratropium: 0.5 mg nebulizer solution = 4 MDI puffs
Category: Toxicology
Keywords: chemical transfer, unlabeled bottle, poison center (PubMed Search)
Posted: 10/29/2020 by Hong Kim, MD
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Transfer of chemical from their original container to an unlabeled or different container (e.g. Gatorade bottle) is one of the common causes of unintentional poisoning.
A retrospective study of National Poison Data System from 2007 – 2017 identified 45,512 cases of unintentional exposure/ingestion of chemicals contained in unlabeled/incorrectly labeled containers.
Result
Annual reported cases increased from 3,223 in 2007 to 5,417 in 2017.
Most commonly involved products included
These exposures led to
The majority of these exposures were non-toxic in nature (72%) but serious outcomes were noted in 4.4% of the cases, including 23 deaths.
Highest morbidity was associated with:
Deaths
Conclusion
Carpenter JE et al. Poisonings due to storage in a secondary container reported to the National Poison Data System, 2007-2017. Clin Toxicol (Phila) 2020.
https://doi.org/10.1080/15563650.2020.1833026
Category: Orthopedics
Keywords: Elbow, dislocation, instability (PubMed Search)
Posted: 10/25/2020 by Brian Corwell, MD
(Updated: 11/26/2024)
Click here to contact Brian Corwell, MD
Ulnar Collateral ligament injuries of the elbow
Overhead throwing athletes are at risk of insufficiency and rupture of the ulnar collateral ligament (UCL) of the elbow
This can lead to valgus instability similar to what can occur in the knee
Overhead throwing places a significant valgus stress on the elbow
Though classically seen in baseball pitchers, may also be seen in javelin throwers and other high velocity throwing sports
In the acute setting may be seen after an elbow dislocation
History includes a “pop” and medial elbow pain following throwing activities
In cases of overuse injury, athletes will report a progressive loss of velocity, accuracy, and/or endurance with throwing.
The ulnar collateral ligament is the primary restraint to valgus stress from 30 to 120 degrees of flexion
One classic test for UCL instability is the milking maneuver
Patient may be sitting or standing
Patient’s forearm is supinated and elbow flexed at 90 degrees
A valgus force is applied by pulling the patient’s thumb while the examiner’s other hand stabilizes the elbow and palpates the medial joint line.
Instability, pain or apprehension at the UCL is considered a positive test
https://www.youtube.com/watch?v=gbn24X_qqn0
Category: Critical Care
Keywords: NAC, Liver Failure, n-acetylcysteine (PubMed Search)
Posted: 10/20/2020 by Mark Sutherland, MD
(Updated: 11/26/2024)
Click here to contact Mark Sutherland, MD
N-acetylcysteine (NAC) is well known as the accepted antidote for acute acetaminophen (tylenol/paracetamol) overdose and is well studied for this indication. While the literature base is not nearly as strong in other causes of acute liver failure, NAC is increasingly used in these scenarios as well. In the emergency department in particular, the cause of fulminant hepatic failure is often not known. NAC may have some protective benefit in non-acetaminophen acute liver failure. Existing data do not show a mortality benefit to NAC in non-acetaminophen acute liver failure, but do show improvement in transplant-free survival. The AASLD guidelines (last revised in 2011) do not comment on NAC in non-acetaminophen acute liver failure. A common practice is to continue NAC until the INR is < 2 and AST/ALT have decreased at least 25% from their peak values.
Patients in fulminant liver failure should also be strongly considered for transfer to a center that does liver transplant, if presenting to a non-transplant center. The King's College criteria is the most commonly used prognostic score for determining need of transfer to a transplant center, but in addition to calculating a King's College score providers should generally consider consultation with a transplant hepatologist for any fulminant liver failure patient to discuss the risks/benefits of transfer for transplant evaluation.
Bottom Line: While not as strongly indicated as it is in acute acetaminophen induced liver failure, NAC should be considered in both non-acetaminophen liver failure and liver failure of unknown etiology. In addition, strongly consider consultation with a transplant hepatologist in any case of fulminant hepatic failure.
Teriaky A. The role of N-acetylcysteine in the treatment of non-acetaminophen acute liver failure. Saudi J Gastroenterol. 2017;23(3):131-132.
October 2020 EMRAP: Critical Care Mailbag
MDCalc King's College Criteria: https://www.mdcalc.com/kings-college-criteria-acetaminophen-toxicity
Category: Pediatrics
Keywords: GU anomaly, prepubescent (PubMed Search)
Posted: 10/16/2020 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD
A labial adhesion is defined as a thin avascular clear plane, a raphe, between the labia minora. These adhesions which can be caused by minor trauma or infection in the absence of estrogen can cause varying degrees of obstruction.
Loveless M, Myint O. Vulvovaginitis- presentation of more common problems in pediatric and adolescent gynecology. Best Pract Res Clin Obstet Gynaecol. 2018 Apr;48:14-27. doi: 10.1016/j.bpobgyn.2017.08.014. Epub 2017 Sep 5. PMID: 28927766.
Bacon JL, Romano ME, Quint EH. Clinical Recommendation: Labial Adhesions. J Pediatr Adolesc Gynecol. 2015 Oct;28(5):405-9. doi: 10.1016/j.jpag.2015.04.010. Epub 2015 Apr 24. PMID: 26162697.
Category: Toxicology
Keywords: dihydropyridine, ARBs, ACEIs, co-ingestion, hypotension, toxicity (PubMed Search)
Posted: 10/15/2020 by Hong Kim, MD
Click here to contact Hong Kim, MD
Dihydropyridine (calcium channel blocker) overdose is one of the leading causes of death from cardiovascular drug poisoning. In contrast, angiotensin-II receptors blockers (ARBs) and angiotensin converting enzyme inhibitor (ACEIs) causes minimal toxicity in overdose. Frequently, these medications are co-ingested with dihydropridines.
Recently, a retrospective study was conducted to evaluate the hemodynamic impact of dihydropyridines with ARBs/ACEIs co-ingestion.
Results
Cohort
Mixed overdose group had:
Higher proportion of the mixed overdose group received:
Conclusion
Combined overdose of dihydropyridines with ARBs/ACEIs can result in more significant hypotension.
Huang J et al. Angiotensin axis antagonists increase the incidence of haemodynamic instability in dihydropyridine calcium channel blocker poisoning. Clint Toxicol (Phila) 2020. Epub. https://doi.org/10.1080/15563650.2020.1826504
Category: Neurology
Keywords: CNS, PNS, UMN, LMN, reflex, Babinski, tone (PubMed Search)
Posted: 10/14/2020 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD
Central Nervous System | Peripheral Nervous System | |
Pattern of Symptoms | • Hemibody involvement • Weakness of UE extensors • Weakness of LE flexors | • Distal involvement in polyneuropathy • Distal and proximal involvement in polyradiculoneuropathy • Proximal involvement in polyradiculopathy • Sensory often precedes motor symptoms • Pure proximal>distal weakness may be due to myopathy or NMJ disorder |
Sensory Symptoms | • Central poststroke pain (hyperalgesia, allodynia) • Sensory level in spinal cord pathology • Proprioception involved early in dorsal column disorders | • Neuropathic pain (burning, tingling, shock-like) • Ascending sensory loss involving distal BLE>BUE in polyneuropathy • Proprioception involved late in polyneuropathy |
Reflexes | • Hyperreflexia in affected limb(s) after acute period • Positive Babinski’s sign | • Hyporeflexia in affected limb(s) |
Tone | • Increased after acute period | • Decreased |
Category: Critical Care
Posted: 10/13/2020 by Mike Winters, MBA, MD
(Updated: 11/26/2024)
Click here to contact Mike Winters, MBA, MD
Blood Pressure Management in Acute Ischemic Stroke
Herpich F, et al. Management of acute ischemic stroke. Crit Care Med. 2020; 48(11):1654-1663.
Category: Orthopedics
Keywords: Carpal Tunnel Syndrome, neuropathy (PubMed Search)
Posted: 10/10/2020 by Brian Corwell, MD
(Updated: 11/26/2024)
Click here to contact Brian Corwell, MD
Carpal Tunnel Syndrome (CTS)
The hallmark of classic CTS: pain or paresthesia (numbness and tingling) in a distribution that includes the median nerve territory, with involvement of the first three digits and the radial half of the fourth digit.
The symptoms of CTS are typically worse at night and often awaken patients from sleep.
Fixed sensory loss is usually a late finding
Involves the median-innervated fingers BUT spares the thenar eminence.
This pattern occurs because the palmar sensory cutaneous nerve arises proximal to the wrist and passes over, rather than through, the carpal tunnel.
Consider a more proximal lesion in cases involving sensory loss in the thenar eminence
Example: pronator syndrome