UMEM Educational Pearls

Nitroglycerin is a potent vasodilator used most commonly for the treatment of angina and ACS.  It can also be administered as a continuous infusion for acute management of a hypertensive emergency or sympathetic crashing acute pulmonary edema.  

Most are aware of asking men for history of medications for erectile dysfunction (PDE5 inhibitors: sildenafil, tadalafil, vardenafil) but many overlook the fact that men and women may be on these medications chronically for pulmonary hypertension. Men can also be on these medications for the treatment of BPH. Be broad in your history taking and do not limit the discussion to erectile dysfunction or a specific gender.

Drug interaction:

-PDE5 inhibitors prevent the breakdown of cGMP

-Nitrates are nitric oxide donors that increase the production of cGMP

-The combination can lead to excessive vasodilation

If accidentally co-administered:

There is no antidote for this medication error.  Support the patient with Trendelenburg positioning, fluid administration, and if needed, vasopressors such as norepinephrine until blood pressure stabilizes.

How long should you wait to administer nitrates after a patient takes a PDE5 Inhibitor?

Sildenafil and vardenafil: 24 h after last dose*

Tadalafil > 48 h after last dose*

*Even if acute ACS event

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Acute appendicitis is the most common etiology requiring urgent abdominal surgery in children in the United States. Peak incidence occurs in the second decade of life, with male patients being more commonly affected than female patients. Classic manifestations of appendicitis occur in school-aged children and adolescents, but are often absent in younger children. Infants and young children <5 years are more likely to present with nonspecific or atypical findings, resulting in delays in diagnosis and higher rates of perforation.

Diagnosis is aided by clinical factors, lab findings, and ultrasound (+/- CT or MRI if ultrasound is equivocal).

Historically, the standard of care for acute appendicitis has been urgent operative management. However, in the past several years, there has been increasing literature supporting nonoperative management (antibiotics only) in adult patients with acute uncomplicated appendicitis. Additionally, there is a growing body of evidence demonstrating the safety and efficacy of nonoperative management for uncomplicated appendicitis in children.

Hartford and Woodward provide a review of the current literature on the nonoperative management of uncomplicated appendicitis in children. They conclude:

-       The majority of recent prospective studies demonstrate early treatment success (0-30 days) of approximately 90% in pediatric patients undergoing nonoperative management.

-       Factors associated with failure of nonoperative management in pediatric appendicitis: longer duration of symptoms (>48 hours), younger age (<5 years), and presence of appendicolith.

-       Nonoperative management has been associated with

o   Lower healthcare costs at 1 year

o   Fewer disability days at 1 year

o   No significantly different rate of complicated appendicitis

-       Most trials to date involve a 24-48 hour initial course of broad spectrum IV antibiotics followed by oral antibiotics for a total of >/= 7 days as nonoperative management. Currently, there is no consensus on antibiotic regimen.

Bottom Line: Given the current evidence, nonoperative management may be a viable treatment option for low risk pediatric patients with uncomplicated appendicitis. The literature is not conclusive, thus we as medical providers in conjunction with our surgical colleagues, should consider numerous factors when discussing treatment options for acute appendicitis with patients and their families.

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Historically, there has been debate on transporting outside hospital cardiac arrests, as well a trauma, with the question of whether to "scoop and run" or "stay and play". 

Could hasty transportation of cardiac arrest patients put a damper on resuscitation quality? 

A recent propensity-matched study in JAMA analyzed 192 EMS agencies across 10 N American sites.

Methods:

-Resuscitation Outcomes Consortium Cardiac Epidemiologic Registry, which counted 43,969 consecutive cases of nontraumatic adult EMS-treated OHCA (median age 67, 37% of whom were women) in 2011-2015.

-25% of these patients were transported to the hospital

-Matched 1:1 with patients in refractory arrest who were resuscitated on scene 

-Primary outcome was survival to hospital discharge, secondary outcome survival to hospital discharge with a favorable neurological status 

Results:

-Duration of out-of-hospital resuscitation was only 6 minutes longer in the intra-arrest transport group (29.1 and 22.9 minutes; not a statistically significant difference)

-Survival to hospital discharge was 3.8% for patients who underwent intra-arrest transport and 12.6% for those who received on-scene resuscitation

-In the propensity-matched cohort, which included 27,705 patients, survival to hospital discharge occurred in 4.0% of patients who underwent intra-arrest transport vs 8.5% who received on-scene resuscitation (risk difference, 4.6% [95% CI, 4.0- 5.1])

-Favorable neurological outcome occurred in 2.9% of patients who underwent intra-arrest transport vs 7.1% who received on-scene resuscitation (risk difference, 4.2% [95% CI, 3.5%-4.9%])

-Intra-arrest transport during resuscitation was associated with worse odds of survival to hospital discharge compared to on-scene resuscitation (4% vs 8.5%, RR 0.48, CI 0.43-0.54)

-Findings persisted across subgroups of initial shockable rhythm vs. non-shockable rhythms (most common initial rhythm was aystole), as well as EMS witness arrests vs. unwitnessed arrests 

Conclusion:

-This study does not support the routine transportation of patients in cardiac arrest during rescuscitation.

-The neurologically intact survival benefit associated with on-scene resuscitation is both impressive and intriguing.

-However, what implications could this have on ECPR? 

Limitations:

-Potential bias due to observational nature of study 

-Duration of resuscitations very similar, unknown exactly how long transport times were or if this was in urban or rural populations

-External validity not generalizable due to heterogeneity of patient populations and EMS systems

-Further randomized clinical trials are required

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Physical injury patterns associated with physical elder abuse

Elder abuse is both common and underrecognized

Between 5 and 10% of US older adults are victims of elder abuse annually

For many older adults, contact with a health care provider may represent their only contact outside the home

Differentiating physical elder abuse from unintentional trauma can be very difficult

A recent study compared these two groups with a case-control design

Study cases: 100 successfully prosecuted physical elder abuse cases from a single urban ED

Physical abuse victims were more likely to have:

               Bruising (78% vs. 54%)

               Injuries to maxillofacial, dental or neck region (67% vs. 28%)

                              Particularly the LEFT side

                              Neck injuries 6x more common is assault

                              Ear injuries occurred in assault but not in falls

               Absence of fracture (8% vs. 22%)

               Less likely to have lower extremity injuries (9% vs. 41%)

22% of victims had no visible injuries

Most common mechanism assault with hands or fists and pushing or shoving causing a fall

Take home: Consider elder abuse especially in cases of the above red flags

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Question

What medication ingestion can lead to black urine?

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Attachments

• 2009241429_Black_urine.docx (115 Kb)

• We've talked about the rising incidence of cerebral venous thrombosis (CVT) and choice of neuroimaging studies before, now let’s talk about presentation and treatment.
• Symptoms range from headache to coma with cerebral edema and intracranial hypertension depending on the veins and sinuses involved.
  • Superior sagittal sinus is most frequently affected (62%) and can cause headache, hemiparesis, hemisensory loss, hemianopia, and seizures.
  • Transverse sinus is also commonly involved (45%) and can cause headache, aphasia, and seizures.
  • Thrombosis of the deep veins is seen in 18% of cases and can cause altered mental status, coma, and gaze palsy.
• Management includes anticoagulation, treatment of underlying cause, seizures, and intracranial hypertension.
  • LMWH is preferred unless in patients with renal dysfunction or need for rapid reversal of anticoagulation.
  • Endovascular intervention may be considered in severe cases that do not improve or deteriorate despite anticoagulation.
• Poor prognostic factors are: 
  • 2 points each - malignancy, coma, deep venous thrombosis
  • 1 point each - mental status disturbances, male, intracranial hemorrhage
  • Score ≥3 suggests high risk of poor outcome

Bottom Line: Severity of CVT presentation depends on the location and clot burden. Anticoagulation is key, though consider endovascular intervention if patient does not improve or deteriorates despite anticoagulation.

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A retrospective study analyzed data from 757 patients with spontaneous intraparenchymal hemorrhage.

Within the first 6 hours of admission, patients who had systolic blood pressure reduction between 40 – 60 mm Hg (OR 1.9, 95% CI 1.1-3.5) or reduction ≥ 60 mm Hg (OR 1.9, 95%CI 1.01-3.8) were associated with almost double likelihood of poor discharge functional outcome (defined as modified Rankin Scale 3-6).

Additionally, large systolic blood pressure reduction ≥ 60 mm Hg in patients with large hematoma (≥ 30.47 ml) was associated with higher likelihood of very poor functional outcome (mRS 5-6).

Take home points: while more studies are still needed to confirm these observations, perhaps we may not want to drop blood pressure in patients with spontaneous intraparenchymal hemorrhage too much and too fast.

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Systematic review and meta-analysis of 5 studies with a total of 929 patients comparing early vs. late initiation of norepinephrine in patients with septic shock

• all were single-center studies
• included RCTs, prospective and retrospective cohort studies

Primary outcome:

• short-term mortality of the early group was lower than that of the late group ([OR] = 0.45; 95% CI, 0.34 to 0.61)

Secondary outcome:

• no difference in ICU LOS
• time to achieved target MAP of the early group was shorter than that of the late group (mean difference = − 1.39; 95% CI, −1.81 to −0.96)
• in the three studies that assessed the volume of intravenous fluids within 6 h, the volume of intravenous fluids within 6 h of the early group was less than that of the late group (mean difference = − 0.50L; 95% CI, −0.68 to −0.3)

Caveat:

• no clear definition of “early” initiation (ranged from within 1 to 6 hrs)

Take home point:

Early norepinephrine usage may improve mortality in septic shock

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- Urethral prolapse will appear as a protrusion of the distal urethra through the urinary meatus causing a “doughnut” sign.

- Risk factors include trauma, UTI, anatomical differences, and increased intraabdoiminal pressure from cough or constipation.  There is a higher incidence in people of African descent.

- The chief complaint may include urethral mass and vaginal bleeding.

- There is a bimodal age distribution (prepuberty and postmetapause) due to a relative estrogen deficiency.

-Treatment is with estrogen cream and sitz baths for 4- 6 weeks.

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A recent study looked at thoracic spinal fractures in the era of the trauma panscan

NEXUS Chest CT Study from 2011 to 2014 at 9 Level I trauma centers.

Goal: To describe the identification rate and types of thoracic spine fractures.

Inclusion: age over 14 years, blunt trauma occurring within 6 hours of ED presentation, and chest CT imaging during ED evaluation.

11,477 subjects, 217 (1.9%) had a thoracic spine fracture

The majority of spine fractures in patients who had both chest x-ray and CT were observed on CT only (91%). 50% had more than 1 thoracic spinal level involved (mean 2.1). 22% had associated cervical fractures and 25% had associated lumbar fractures.

               64% had vertebral body fractures

               45% had posterior column fractures

               28% had compression fractures

               6% had burst fractures

Many patients (62%) had associated thoracic injuries such as

               Rib fractures (45%)

               PTX (36%)

               Clavicle fracture (18%)

               Scapular fracture (17%)

               Hemothorax (15%)

100 patients had clinically significant thoracic spine fractures.

Thoracic spine fractures are relatively uncommon in adult patients with blunt trauma.

If thoracic spine fracture is suspected clinically, radiography is not an effective screen and clinician should consider CT. If not suspected, guidelines discourage ordering CT to screen for this injury because of effective screening instruments, the diagnosis of clinically insignificant injuries and radiation exposure.

All clinically significant thoracic spine fractures would have been detected by the NEXUS Chest CT decision instrument.

https://www.mdcalc.com/nexus-chest-ct-decision-instrument-ct-imaging

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Extracorporeal membrane oxygenation use is increasing in the US for acute poisoning. 

A retrospective study of the National Poison Data System from 2000 to 2018 identified 407 ECMO cases (332 adults – age > 12 years, 75 pediatric – age < 12 years). Increase in ECMO use were more notable in adult population.

Characteristics

• Median age: 27 years (IQR: 15-39)
• Male: 52.6%
• Single substance exposure: 51.5%
• Median number of exposures: 3 (IQR: 2-4)
• Overall survival: 70%

Intentional exposure

• Age > 12 years: 72.6%
• Age < 12 years: 9.3%

Most common class of drug/poison exposure in adults

• Sedative/hypnotic: 26%
• Antidepressants: 25%
• Calcium channel blockers: 19%
• Opioids: 17%

Most common class of drug/poison exposure in children

• Hydrocarbons: 37%
• Antiarrhythmics: 15%
• Antihistamine: 8%
• Unknown: 8%

Most common states that used ECMO for poisoning

• Pennsylvania: 45
• Texas: 27
• Minnesota: 24
• Maryland: 22
• Michigan: 20
• New York: 20

Conclusion

• Increase in EMCO use was most notable in patients with age > 12 years
• There was no significant trend in mortality during the study period
• ECMO cases were mostly reported from urban areas 

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While the invasive monitoring of central venous pressure (CVP) in the critically ill septic patient has gone the way of also transfusing them to a hemoglobin of 10 mg/dL, it remains that an elevated CVP is associated with higher mortality^1,2 and renal failure.^2,3

Extrapolating from existing data looking at hepatic vein, portal vein, and renal vein pulsatility as measures of systemic venous hypertension and congestion,^4,5,6 Beaubien-Souligny et al. developed the venous excess ultrasound (VExUS) grading system incorporating assessment of all 3, plus the IVC, using US to stage severity of venous congestion in post-cardiac surgery patients.⁷ They evaluated several variations, determining that the VExUS-C grading system was most predictive of subsequent renal dysfunction.

(Image from www.pocus101.com)
 

High Points

       VExUS Grade 3 (severe) venous congestion:

• Correlated with higher CVP & NTproBNP levels, as well as overall fluid balance
• Had a 96% specificity for development of subsequent AKI

Caveats

• Evaluating all parameters yields the most benefit to avoid false positives
• Can be difficult to obtain all views (>25% of subjects excluded due to poor US image quality)
• Studied in a limited population, notably not primarily RV failure patients

Clinical Uses

• To limit harmful fluid administration in shock
• To help answer the prerenal vs cardiorenal AKI question in CHF
• To indicate when volume removal (diuresis) should be the strategy, even in patients with vasopressor-dependent shock

A great how-to can be found here:

https://www.pocus101.com/vexus-ultrasound-score-fluid-overload-and-venous-congestion-assessment/

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Ingestion of a button battery is a can't-miss diagnosis with a very high risk for causing severe esophageal injury. There are about 3000 button battery ingestions per year, and this is increasing because electronics are becoming more and more prevalent.

Severe damage to the esophagus occurs within 2 hours. On your lateral view, the end with narrowing is the negative end, which triggers a hydrolysis reaction that results in an alkaline caustic injury and, ultimately, liquefactive necrosis.

Children can present with nonspecific symptoms and if the ingestion was not witnessed, they are at high risk for delays in diagnosis. Additionally, in the community setting, there can be further delays in definitive treatment (endoscopic removal) due to difficulty in calling teams in or transporting to other facilities.

Anfang et al. looked into ways to mitigate damage to esophageal tissue. They did an in vitro study on porcine esophageal tissue, measuring the pH with different substances applied. They tried apple juice, orange juice, gatorade, powerade, pure honey, pure maple syrup, and carafate. They then repeated the study in vivo on piglets with button batteries left in the esophagus and ultimately did gross and histological examination of the esophageal tissue.

Honey and carafate demonstrated protective effects both in vitro and in vivo. They neutralized pH changes, decreased full-thickness esophageal injury, and decreased outward extension of injury into deep muscle.

Take Home Point: If a child is found to have a button battery in the esophagus, while definitive management is still emergent endoscopic removal, early and frequent ingestion of honey (outside of the hospital) and Carafate (in the hospital) may help reduce the damage done to the tissue in the interim. The authors recommend 10ml every 10 minutes.

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STARRT-AKITrial

The Standard versus Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury

The development of acute kidney injury (AKI) in the critical care setting portends a greater morbidity and mortality for patients. Additionally, it places the patient at high risk of complications and requires a greater use of resources. Several studies in the past have examined if the timing of initiation of renal replacement therapy (RRT) would result in a mortality benefit, but have failed to demonstrate consistent outcomes.

The STARRT-AKI trial was a multinational, randomized controlled trial designed to determine if early initiation of RRT in critically ill adult patients with AKI lowered the risk of 90-day mortality. The Kidney Disease Improving Global Outcomes (KDIGO) classification was used to define AKI and over 2900 patients were randomly assigned to two groups over a 4 year period. Exclusion criteria included: recent RRT, a renal transplant within the preceding year, advanced CKD, an overdose necessitating RRT, or a strong suspicion of obstruction or autoimmune/vascular cause of their AKI.

Groups:

• The accelerated strategy group
  • Initiation of RRT within 12 hours of meeting eligibility criteria (AKI based on KDIGO definition)
• The standard strategy group –
  • General goal of withholding RRT unless the patient met the following specific parameters:
  • K+ >6.0,  pH <7.20,  HCO3 <12mmol/L,  moderate ARDS with clinical picture concerning for volume overload, or persistent AKI >72hr after randomization

Outcomes/Results:

• The study’s primary outcome measure was all cause mortality at 90 days
  •  There was no significant difference between the groups
  •  P=0.92 with RR 1.00
• Secondary outcomes evaluated several things including ventilator and vasoactive free days, hospital length of stay, number of days without RRT at 90 days as well as adverse events directly related to RRT
  • Interestingly, at 90 days, the patients in the accelerated strategy group were more likely to have ongoing RRT needs at 10.4% compared to the standard strategy group at 6.0% (not statistically significant).
  •  Overall, no significant difference between the groups when assessed for death in the ICU, major adverse events, or with regard to hospital length of stay.

Take home points:

• This was a well done, well randomized trial from many countries and ICU settings
• No significant mortality benefit between groups at 90 days
• Interestingly, the patients in the accelerated group were more likely to have suffered adverse events related to RRT and were more likely to be dependent on RRT at 90 days
  • It is unclear why this is, but suggestive that early initiation of RRT may compromise the intrinsic healing of the kidney
  • Emphasizes a greater risk for adverse events without clear benefit
• Ultimately, the decision to initiate RRT should be based on the patient’s clinical picture, acid/base status, electrolyte abnormalities, and volume status and NOT on a general trend of their renal indices.

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• Trigeminal neuralgia is diagnosed by:
  • Pain in 1 or more divisions of the trigeminal nerve
  • Paroxysms of pain that are sudden, intense, usually few seconds in duration
  • Pain triggered by innocuous stimuli in the trigeminal nerve territory (91-99% patients)
• 24-49% of patients experience continuous or long-lasting pain
• Exam may reveal forceful contraction of the facial muscles during a paroxysm (tic convulsif)
• Causes include:
  • Intracranial vascular compression of the trigeminal nerve root (most common)
  • Multiple sclerosis, cerebellopontine angle tumor
  • Idiopathic (10% of cases)
• Carbamazepine and oxcarbazepine are first-line treatments
  • They may be poorly tolerated due to side effects including dizziness, diplopia, ataxia, CNS depression, and hyponatremia
  • They also have limited efficacy on continuous pain
• Acute exacerbations may warrant admission for hydration, acute pain control, and titration of antiepileptic drugs
  • Botulinum toxin A was recently added as a treatment option

Bottom Line: New onset trigeminal neuralgia needs workup for its etiology. Carbamazepine and oxcarbazepine can be effective for symptom management though continuous or long-lasting pain exacerbations are difficult to treat.

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Ketamine In the Critically Ill Patient

• Ketamine has become a popular agent in the ED for both RSI and procedural sedation.
• Given the sedative, analgesic, dissociative, antidepressant, and anti-inflammatory properties, ketamine has also been used in a number of other critical illness conditions including:
  • Acute pain management
  • Status asthmaticus
  • Alcohol withdrawal syndrome
  • Status epilepticus
  • Acute agitated delirium
• The authors of a recent review in Critical Care Medicine found that the evidence supporting the use of ketamine in the critically ill is most robust for adjunctive analgesia in the intubated patient.  Surprisingly, the data is very limited to support the use of ketamine in these other conditions.
• Pearl: ketamine does have a myocardial depressant effect, which can be unmasked in states of catecholamine depletion and result in hypotension and bradycadia.

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Diagnostic performance of Ultrasonography for detection of pediatric elbow fracture

Elbow fractures account for approximately 15% of pediatric fractures

Fat pads are traditionally taught as a marker of fracture

In a cadaveric study:

Elbow effusions of 1-3 mL could be identified with ultrasound

Elbow effusions of 5-10 mL could be identified with plain film

Pediatric plain films are sometimes challenging to obtain and interpret compared to adults

              -More likely to be uncooperative in obtaining required views

              -Non-ossified epiphyses

Ultrasound may be used to detect

              -Cortical disruption and irregularity

              -Growth plate widening

              -Hematoma interposed between fracture fragments

              -Elevated posterior fat pad

Absence of elbow fracture was indicated by

              -Lack of cortical disruption

              -Absence of posterior fat pad sign

Meta-analysis of 10 articles totaling 519 patients using ultrasonography to detect elbow fractures

              Sensitivity 96%

              Specificity 89%

              False negative rate 3.7%             

For comparison, plain radiographs

Interpreted by peds EM physicians (87.5% sensitive and 100% specific)

Interpreted by radiology (96% sensitive, 100% specific)

Consider using ultrasound as a noninvasive, radiation-free modality for accurate diagnosis of pediatric elbow fractures.

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Definition: Congenital anomaly where the hymen is completely obstructing the vaginal opening

Demographic: Incidence 0.05-0.1% of females

History:  Most are asymptomatic and diagnosed on physical exam or incidentally when there is lack of menarche. Symptoms in adolescents can include: Abdominal pain (50%), urinary retention (20%), abnormal menstruation (14%), dysuria (10%), frequency, renal failure, UTI and back pain.

Physical exam: bulging, blueish hymenal membrane

Complications: Late detection can lead to infections, fertility problems, endometriosis, hydronephrosis, and rarely renal failure

ED treatment: If abdominal pain is significant or there is urinary obstruction, a urinary foley can be placed.  GYN should be consulted.

Definitive treatment: Hymenectomy, hymenotomy, carbon dioxide laser treatments or foley insertion through the hymen (done by a specialist).

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