Phenytoin can be a complex medication.  There are different levels than can be ordered, adjustments based on albumin, various pharmacokinetic equations, and multiple formulations.  Below are the simplified answers to some of the most common questions (see in-depth section for explanations):

Which phenytoin level (free or total) do I order?

Total Phenytoin Level.

What do I do after the level results?

Undetectable Level: Load patient with 20 mg/kg of total body weight (max dose 1,500 mg).

Subtherapeutic Level (<10 mcg/mL): Calculate an approximate loading dose using this equation….Phenytoin Dose (mg)=(15-measured total level)*(0.7*patient weight).

Therapeutic Level (10-20 mcg/mL): Add an additional agent.

Supratherapetutic/Toxic Level (>20 mcg/mL): Contact Poison Center (1-800-222-1222).

What formulation do I order for loading?

IV: Use fosphenytoin.

PO: Any formulation will work.  Give as a single loading dose or, if concerned for GI upset, give in 2-3 divided doses separated by 2 hours.

***Disclaimer: These answers are simplified for the initial management of most patients in the ED. More complex answers may be required in some situations.***

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Ever been in an acute rescucitation and found yourself unable to remember all of those famous ACLS Hs and Ts?  I know I have.  A few years ago Littman et al published an alternative approach to critically ill, hypotensive medical patients with non shockable rhythms.  Unfortunately, it seems like some of the enthusiasm for this approach has died down, but I still think it's something you're more likely to recall in a pinch than the Hs and Ts and is a better way of getting started with a hypotensive non-trauma patient.  And it's so simple you may actually remember it!

1) Look at the monitor.  Is the rhythm narrow or wide?  

2a) Narrow - more likely a mechanical problem (tamponade, tension PTX, autoPEEP, or PE). Give IVF and search for one of these causes (and correct it!).  Keep in mind that ultrasound can help you differentiate a lot of these.

2b) Wide - more likely a metabolic problem (hyperK, sodium channel blockade, etc*). Give empiric calcium, bicarb, and other therapies targeted for these problems (if desired) and get stat labs.

Take a minute and either go to this REBEL EM post:

https://rebelem.com/a-new-pulseless-electrical-activity-algorithm/

To review this, or look at the attached diagrams.  

*Dr. Mattu would want me to remind you that hyperkalemia IS a sodium channel poisoned state, so there's no need to think of these two separately

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Attachments

• 1910292200_Narrow-Complex-PEA-Management-765x456.jpg (96 Kb)
• 1910292201_Wide-Complex-PEA-Management-765x444.jpg (83 Kb)

A recent epidemiology study in Pediatrics looked at concussions in 20 high school sports during the 2013–2014 to 2017–2018 school years.

For every athlete, one practice or competition was counted as one exposure.

Overall, 9542 concussions were reported for an overall rate of 4.17 per 10 000 athletic exposures (AEs).

Football continues to have the highest incidence with a concussion rate of 10.40 per 10 000 AEs.

As in previous studies, rates in competition (33.19 to 39.07 per 10 000 AEs) are increasing and higher than rates in practice which are lower and decreasing over the study period (5.47 to 4.44 per 10 000 AEs).

            This may reflect better reporting or increasing injury rate

In all 20 sports, recurrent concussion rates decreased from 0.47 to 0.28 per 10 000 AEs.

Confirming prior studies, among sex-comparable sports, concussion rates were higher in girls than in boys (3.35 vs 1.51 per 10 000 AEs).

Also, among sex-comparable sports, girls had larger proportions of concussions that were recurrent than boys (9.3% vs 6.4%).

This study may reflect effective implementation of strategies to reduce concussion incidence such as mandatory removal from play and more stringent requirements associated with return to play.

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• Resuscitation with crystalloid fluid is a cornerstone of pediatric septic shock treatment.
• Recent publication from the adult literature have suggested that balance crystalloid solutions may be better than 0.9% normal saline (NS) for select conditions.
• Lactated Ringer's (LR) is a common balance crystalloid solution often used for fluid resuscitation and critically ill patients.
• However whether resuscitation with balance fluids is associated with improved outcomes compared to NS in pediatric sepsis is unclear.
• A matched retrospective cohort study of 12,529 pediatric patient with severe sepsis/septic shock at 382 US hospitals compared outcomes with versus without LR as a part of the initial resuscitation.
• Outcomes includesd: 30-day hospital mortality, acute kidney injury, new dialysis, and length of stay.
• After matching, mortality was not different between LR and NS groups. There were no differences in secondary outcomes except longer hospital length of stay in the LR groups.
• The PRoMPT BOLUS randomized control trial pilot was a feasibility study designed to study the comparative effectiveness of LR versus NS fluid resuscitation for pediatic septic shock.  Completion of a more robust study may help provide answers to these ongoing questions. 

Bottom line: Balance fluid resuscitation with LR was not associated with improved outcomes compared to NS and pediatric sepsis. Selective LR use necessitates a prospective trial to definitively determine comparative effects among crystalloids.

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Patients with drug-induced cardiogenic shock [DIC] (e.g. overdose of CCB/BB, membrane stabilizing agents, etc.) are often managed with medical interventions such as vasopressors, bicarbonate infusion, high-dose insulin, lipid emulsion therapy. A fraction of these patients may be refractory to the standard medical therapy. VA-ECMO (venoarterial extracorporeal membrane oxygenation) has been utilized in such situation; yet clinical experience of using VA-ECMO in DIC is limited.

A recent retrospective study of the Extracorporeal Life Support Organization’s ECMO registry showed

• Increasing VA-ECMO utilization for drug-induced cardiogenic shock (n=104) over the past 15 years (2003 to 2018) but it represents a fraction (0.067%) of VA-ECMO use.
• VA-ECMO improved hemodynamic and metabolic status at 24 hrs-post cannulation.
• Persistent acidosis (HCO3 level) and acidemia (pH) at 24 hrs-post cannulation was associated with mortality.
• 52.9% of the cases survived to discharge. 

Conclusion

• VA-ECMO may be clinically beneficial (improvement of hemodynamic and metaboic status) in patients with refractory drug-induce cardiogenic shock

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• Cryptococcal meningitis is the most common fungal CNS infection that predominantly affects immunocompromised patients.
• However, cases have been described in immunocompetent patients.
• Clinical presentation may include headache, fever, neck pain, nausea, vomiting, light sensitivity, seizure, or altered mental status.
• Neuroimaging is usually normal, though cryptococcomas, pseudocysts, and obstructing hydrocephalus can be seen.
• Diagnosis with LP include elevated opening pressure, mononuclear predominance of cell count, low glucose, high protein, India ink microscopy, Cryptococcal antigen testing, and CSF culture.
• Subacute symptoms contribute to delay in diagnosis which increases overall morbidity and mortality.

Bottom Line: Consider cryptococcal meningitis even in immunocompetent patients.

ICU admission rates for all acute PEs vary wildly across the country (<5% to ~80%).

To predict which hemodynamically stable, normotensive PE patients should be admitted to the ICU, a single-center retrospective analysis of 7 years’ data sought to describe the reasons why normotensive patients with PE required vasopressors within 48 hours of admission to the ICU. The authors studied 293 patients admitted to the ICU at Beth Israel Deaconess in Boston and found only 8 patients (2.7%) who decompensated within the first 2 days.  Of MANY variables studied, only respiratory rate was significantly different between those who decompensated and those who did not (mean RR 29 with range 26-32 in the decompensated group vs mean 21 with range 17-24).

Bottom Line: cost control experts may lean on you to admit fewer PE patients to the ICU. There is no perfectly reliable way to predict which normotensive patient with a PE will decompensate. The PESI score has been validated but even the low risk cohort had 1.6% mortality at 3 days. The BOVA score has been validated but its endpoint of mortality at 30 days is less useful for planning admission. Tachypnea should concern you.

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The Critically Ill Geriatric Patient with Sepsis

• Due to the age-related physiologic change of immunosenescence, geriatric patients have an increased susceptibility to infection, a decreased ability to mount a response to infection, and an increased likelihood of atypical presentations.
• Atypical presentations of sepsis in the geriatric patient include confusion, decreased functional status, generalized weakness, and failure to thrive.
• In fact, up to 33% of geriatric patients with bacteremia will be afebrile upon presentation.
• Consider sepsis in the differential diagnosis of geriatric patients with these nonspecific complaints.

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Synthetic turf playing surfaces have been growing in popularity over the last decade and seem to have become a new standard.

Due to the need for durable fields that can accommodate multiple teams/activities, in addition to the high cost of maintaining grass and the need to conserve water, many parks and schools have switched from grass to turf. Turf is advertised as maintenance free but ….this is not the case.

Locally, at M&T Bank Stadium, groundskeepers drive a LitterKat turf sweeper across the field for 4 hours 2-3 times a week to ensure that the synthetic rubber is cleaned and distributed evenly. The field is also repainted every 4 games because the paint may become hard. The cost of this level of maintenance is beyond what many parks and local high schools can afford.

A recent study examined high school concussion data at almost 2000 high schools with over 14,000 recorded concussions. Researchers concluded that more concussions occurred in games than practices. Interestingly, they also found that playing surface was significantly associated with concussion. Almost 90% of all injuries occurred on turf-based surfaces. Turf outweighed all other mechanisms of injury, including helmet-to-helmet hits and grass playing surface. Between 10 and 15.5% of concussions occur from helmet to ground contact. In the NFL, this mechanism accounts for about 1 in 7 concussions.

Attempting to limit total exposure time in practice and games on turf surfaces may be beneficial until more study is needed.

The rate of suicide attempt has been increasing over the past decade. A recently published article investigated the temporal trend of suicide attempts in adolescent/young adult population (10 – 25 years old) from 2000 to 2018.

 Methods

• All intentional – suspected suicide cases were identified from the National Poison Data System from Jan 1, 2000 to December 31, 2018. 
• Following age groups were compared: 10-12, 13-15, 16-18, 19-21 and 22-25 years old.

Results

• A total of 1,677,435 cases were identified with 0.1% fatality (n=1579).
• Female: 70.6% (n=1,184,691) 
• Single substance (64.1%; n=1,074,423)
• Highest suicide attempt rate: 16-18 years (30.1%; n=504,682)
• Lowest suicide attempt rate: 10-12 years (2.3%; n=38,428)

• The suicide attempt rate increased significantly starting 2011 in 10-12, 13-15 and 16-19 years age groups with seasonal trend
  •  Higher during school months (Sept to May) vs. non-school months (June-August)

Top 5 substance involved in suicide attempt

1. OTC analgesics
2. Antidepressants
3. Sedative hypnotics
4. Antihistamines
5. Antipsychotics

Agents associated with serious medical outcome (after 2011)

1. Antidepressants
2. OTC analgesics
3. Antihistamines 
4. ADHD medications

• ADHD medicaitons: common in 10-15 years population
• Sedative hypnotics (e.g. benzodiazepines): common in older age group (16-25 years)

Conclusion

• Rate of suicide attempt in adolescent and young adults has increase, especially since 2011.
• The substance used in suicide attempt usually involves medications available to the specific age group.
• OTC medications (analgesics and antihistamines) were involved in a third of the suicide attemps.

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Rationale: Data regarding temperature management in patients suffered from cardiac arrest with nonshockable rhythm was inconclusive.

Objective: whether moderate hypothermia at 33C, compared with normothermia at 37C would improve neurologic outcome in patients with coma after cardiac arrest with nonshockable rhythm.

Outcome: survival with favorable 90-day neurologic outcome (Cerebral Performance Category scale 1-2/5)

SummaryThere was higher percentage of patients achieving CPC 1-2 in the hypothermia group (10.2%) vs normothermia group (5.7%, Hazard Ratio 4.5, 95% CI 0.1-8.9, p=0.04)

This randomized multicenter trial involved 581 patients with cardiac arrest and nonshockable rhythm.  Hypothermia group included 284 patients vs. 297 in the normothermia group.  Median GCS at enrollment = 3.

Majority of patients was cooled with the use of a basic external cooling device: 37% for hypothermia and 50.8% for normothermia group.

There was higher percentage of patients achieving CPC 1-2 in the hypothermia group (10.2%) vs normothermia group (5.7%, Hazard Ratio 4.5, 95% CI 0.1-8.9, p=0.04)

Limitation:

A. The study used strict enrollment criteria:

1. CPR initiation within 10 minutes;
2. CPR to ROSC within 60 minutes;
3. epinephrine or norepinephrine infusion at < 1 ug/kg/min;
4. No Child-Pugh class C liver cirrhosis

B. normothermia group had higher proportion of patients with temperature at 38C.

C. Hypothermia group underwent temperature management of 56 hours vs. 48 hours for normothermia patients.

Take home points:

In a selected group of patients with cardiac arrest and nonshockable rhythm, moderate hypothermia at 33C may improve neurologic outcome.

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E-cigarette (vaping) use has become increasingly popular over the past 10 years, especially among adolescents. Intentional exposure (i.e. ingestion in self harm) of nicotine (e-cigarette liquid) can be life threatening where it can produce mixture of stimulatory (early), cholinergic toxicity and muscle paralysis/respiratory failure by blocking the neuromuscular junction. However, the severity of clinical toxicity in unintentional exposure can vary widely depending on the dose/route/circumstance of their exposure.

A recently published study investigated the characteristics of e-cigarette liquid exposure between Jan 1, 2010 to Dec 31, 2018 using the National Poison Data System

Result

• Total reported exposure: 17,358.
• e-cigarette exposure report increased starting 2013 (n=1435), peaking in 2014 (3742). 2018 (n=2901).

Top 4 clinical/demographic characteristics are listed below.

Age group:

• < 5 years: 64.8%
• 25+ years: 15.4%
• 18-24 years: 8.3%
• 12-17 year: 3.4%

Route of exposure

• Ingestion: 77.5%
• Dermal: 13.0%
• Inhalation/nasal: 10.4%
• Ocular: 7.1% 

Level of care:

• Not referred to health care facility (HCF): 60.9%
• Treated and released from HCF: 27.4%
• Admitted: non-critical care: 0.8%, critical care: 0.6%

Clinical effects - overall

• Vomiting: 25.4%
• Nausea: 11.8%
• Ocular irritation: 11.3%
• Dizziness/vertigo: 5.1%

In <5 years group

• Vomiting: 47.1%
• Cough/choking: 10.2%
• Drowsiness/lethargy: 5.7%
• Nausea: 5.5%

Conclusion

• e-cigarette exposure predominantly occurs in young children (< 5 y/o)
• Clinical toxicity are usually self-limited and often not referred to HCF.
• Severe toxicity is possible, although infrequent, from unintentional exposure.

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Blood Transfusion Thresholds in Specific Populations

Sepsis - 7 g/dL

• non-inferior to 9 g/dL (which was previously recommended in early goal-directed therapy and early Surviving Sepsis guidelines)

Acute Coronary Syndrome - no current specific recommendations pending further studies

• recent MINT pilot study showed unexpected trend toward higher combined mortality and major cardiac events in restrictive transfusion arm (8 g/dL) vs. liberal arm (10 g/dL)

Stable Cardiovascular Disease - 8 g/dL

• no difference in 30-day mortality compared to 10 g/dL, excluding those who have undergone cardiac surgery

Gastrointestinal Bleeds

• UGIB - 7 g/dL (unless intravascularly volume depleted or h/o CAD)
  • better 6 week-survival, less re-bleeding compared to 9 g/dL
• LGIB - 7 g/dL, limited evidence, but based on UGIB data

Acute Neurologic Injury - Traumatic Brain Injury - 7 g/dL

•  no significant difference in neurologic recovery at 6 weeks or mortality vs. 10 g/dL, although there were more brain tissue hypoxia events in restrictive arm
•  anemia and transfusions both associated with worse outcomes in TBI

Postpartum Hemorrhage - 1:1:1 ratio strategy

• FFP/RBC ratio ≥  1 associated with improved patient outcomes

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Intersection Syndrome

De Quervain’s is a common tenosynovitis is involving the  the 1^st dorsal compartment of the wrist/forearm.

Intersection syndrome is a tenosynovitis that occurs at the intersection of the 1^st and 2^nd dorsal compartments.

Pathology located at crossing point of the 1^st compartment structures (APL and EBP) with the radial wrist extensors (ECRB and ECRL)

Occurs most commonly from repetitive wrist extension and is common in rowers, weight lifters, and in those playing racquet sports.

Occurs about 4 to 6cm proximal to the radiocarpal joint VERSUS De Quervain’s which occurs near the level of the radial styloid.

Pain worse with resisted wrist and thumb extension

Radiographs not required

Splint and start NSAIDs

Recalcitrant cases can be referred for corticosteroid injection

https://stemcelldoc.files.wordpress.com/2012/09/intersection-syndrome-referral-pain-pattern1.jpg

• The ACEP clinical policy on the evaluation and management of acute nontraumatic headache in the ED was recently updated.
• Similar to prior policies, it focuses on the diagnosis of subarachnoid hemorrhage (SAH) due to the disproportionate amount of literature in comparison to other high risk etiologies.
• In summary:

• 1. Are there risk-stratification strategies that reliably identify the need for emergent neuroimaging?
     • The Ottawa SAH Rule has a high sensitivity but low specificity for patients presenting with a normal neurological exam and peak headache intensity within 1 hour of symptom onset (Level B recommendation).
     • Caution in application of this rule, as use in the incorrect population may increase unnecessary testing.
  2. Are nonopioids preferred to opioids for treatment of acute primary headache?
     • Preferentially use nonopioid medications in the treatment of acute primary headaches in ED patients (Level A recommendation).
     • Consider discharge medication and education to reduce headache recurrence and repeat ED visit.
  3. Does a normal noncontrast head CT performed within 6 hours of headache onset preclude the need for further diagnostic workup for SAH?
     • Noncontrast head CT using at least a 3rd generation scanner performed within 6 hours of headache onset can be used to rule out nontraumatic SAH (Level B recommendation).
     • If clinical suspicion remains high despite the negative noncontrast head CT, further evaluation may be pursued.
  4. In a patient who is still considered to be at risk for SAH after a negative noncontrast head CT, is CTA as effective as LP to rule out SAH?
     • Use shared decision making to select the best modality for each patient after weighing the potential for false-positive CTA and the pros/cons associated with LP (Level C recommendation).

• This clinical policy does not address the evaluation of other potential etiologies for acute headache, including in the pregnant woman and postpartum woman. 

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The U.S. is currently experiencing an epidemic of a severe lung disease termed Vaping-Associated Pulmonary Illness (VAPI), with over 500 cases and 7 deaths across 38 states and 1 U.S. territory since July 2019.

The clinical presentation of VAPI varies -- 

• Respiratory (SOB, cough, chest pain), constitutional (fever, tachycardia, headache, dizziness), and potentially GI symptoms (vomiting, diarrhea) after the use of vaping devices. GI symptoms may precede respiratory issues.
• Can take days or worsen over weeks and can present or end up with severe respiratory failure

Diagnostics --

• Labs nonspecific: Leukocytosis, elevated ESR, no specific infectious etiology
• Chest CT generally with bilateral infiltrates
• Bronchoscopy with BAL demonstrates PMNs and may have lipid-laden macrophages on Oil red O or Sudan staining

Treatment is supportive +/- steroids -- 

• Current recommendations to treat similarly to ARDS in intubated patients
• Potential benefit to steroids if not contraindicated

Bottom Line: Include vaping-associated pulmonary illness in your differential for patients presenting with acute lung disease.

• Ask patients about use of e-cigarette/vaping devices.
• Notify the CDC or your state health department of any suspected cases.
• Counsel your patients to avoid the use of these devices, at the very least until the specific causative agent is found.

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-       Tibial tubercle avulsion fractures are rare and pediatrics, accounting for less than 3% of all epiphyseal injuries in children ages 11-17 years. 

-       The typical mechanism is a sudden forceful quadriceps contraction.  Patients present with sudden pain after sprinting or jumping with pain, bruising, deformity or swelling over the tibial tubercle and with a decrease ability to extend the leg. 

-       10 to 20% of cases result in anterior compartment syndrome related to the rupture of the anterior tibial recurrent artery.

-       Although directly measured intra-compartmental pressures can facilitate the diagnosis of compartment syndrome, interpretation of these values can be challenging with healthy children having higher average lower leg compartment pressures than adults.  Treatment of subsequent compartment syndrome is often based on a high index of suspicion.

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Cannabinoid hyperemesis syndrome [CHS] (i.e. cyclic/recurrent nausea, vomiting and abdominal pain) is associated with long-term and frequent use of marijuana. Patients with CHS often report temporary relief of symptoms with hot water/shower exposure. Emergency room providers may encounter a growing number of patients with CHS with increasing legalization of marijuana-containing products.

Topical capsaicin has been gaining interest as a potential adjunct to the conventional management of patients with CHS (e.g. antiemetics, opioids, benzodiazepines and antipsychotics).

A small retrospective study was performed involving 43 patients who had multiple visits, and were treated with and without capsaicin. The primary outcome was the ED length of stay (LOS).

Results

• Most frequently administered medications in both groups were:

1. Anti-emetics
2. Haloperidol
3. Diphenhydramine 

• Median ED LOS: no significant difference
  • Capsaicin vs. non-capsaicin: 179 min (IQR: 147, 270) vs. 201 min (IQR: 168, 310) (p=0.33)

• Capsaicin group showed
  • Decreased opioid used: 69 mg vs. 166.5 mg oral morphine equivalents
  • Fewer additional medication administration: 3 vs. 4 doses (p=0.015)
  • Shorter median time to discharge after last medication administration: 60 min (IQR: 35, 115) vs. 92 min (IQR: 47, 155) (p=NS) 

• 67% of the visit where capsaicin was used required no additional medication.

Conclusion

• Capsaicin use did not decrease ED LOS.
• However, there was a decrease in total medications administered and opioid requirement.

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Most non-OB physicians experience some fear or anxiety over taking care of the average pregnant patient. There are two patients to consider when caring for these women. Critical illness adds another layer of complexity to an already challenging patient population. Due to the normal physiologic changes that occur during pregnancy there are specific and important factors to be aware of when considering and preparing for intubation.

• Difficult intubations occur up to 5% of pregnant women.
• Edema occurs in the OP regions resulting in a narrowed OP diameter, especially with advancing gestational age. A smaller than anticipated ET tube might be necessary.
• Weight gain and/or obesity make visualization difficult Consider the ramp position to bring the external auditory meatus and the sternal notch into a horizontal line.
• Aortocaval compression decreases blood return to the heart and can result in hypotension on induction. Consider the use of a wedge under the patient’s right hip to decrease compression during intubation, especially those in later stages of pregnancy.
• Risk of aspiration is increased due to decreased lower esophageal sphincter tone. Consider administering metoclopramide prior to intubation which selectively increases esophageal sphincter.
• Functional residual volume in addition to increased oxygen consumption and metabolic demand lead to quicker desaturations and a greater intolerance to hypoxia and apnea. 
• Be prepared with back up or adjunctive airway options including a video laryngoscope (like Glidescope), an LMA or a supraglottic airway. Although the LMA and supraglottic airways are rescue options in the setting of failed ET intubation, they can often adequately oxygenate and ventilate while urgently consulting with anesthesia colleagues in order to obtain a definitive airway.

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