UMEM Educational Pearls

This study, done out of Australia, examined the association between abdominal pain and severity of liver injury in patients presenting after acute acetaminophen overdose. 

539 cases were identified where N-acetylcysteine was administered to patients with acetaminophen overdose. The investigators explored parameters including presence of abdominal pain, time post-ingestion, and peak ALT. 

Patients less than 8 hours post overdose WITH abdominal pain were as likely to develop hepatotoxicity as those presenting WITHOUT abdominal pain. (OR=1.18 [0.07 to 19.4])

Patients presenting 8 or more hours post overdose WITH abdominal pain were as likely to develop hepatotoxicity as those WITHOUT abdominal pain (OR=1.28 [0.39 to 4.21])

Don't let lack of pain fool you! Just as we all learned in medical school - let your history be your guide!

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Diabetic ketoacidosis (DKA) is a serious condition that carries the risk of significant morbidity and mortality if not managed appropriately. Typically managed with an infusion of regular insulin, IV fluids, and electrolytes, there is evidence to support treatment of mild to moderate DKA with a subcutaneous (SQ) regimen using a combo of fast-acting and long-acting insulin instead, decreasing the need for ICU admission without increasing adverse events [1].  

What patients? 

• Isolated DKA without other ICU requirements 
• Mild-moderate severity as described below [2].

Adapted from Abbas et al. 

How to manage? 

• These patients still require aggressive fluid replacement, frequent POC & BMP monitoring, aggressive electrolyte repletion and treatment of any underlying precipitating cause for their DKA.   
• Insulin dosing should not be started until adequate electrolyte repletion has occurred. 
• There is no universally-accepted protocol and several exist [1-4].   A reasonable approach:

Initial dose 

• Insulin long-acting (glargine) 0.2 to 0.3 units/kg SQ or patient’s home dose 
• Insulin fast-acting (aspart/lispro) 0.3 units/kg SQ

Subsequent dosing: 

If serum glucose is > 250 mg/dL 

• Insulin short-acting 0.2 units/kg every 2 -4 hours

If serum glucose is < 250 mg/dL 

• Insulin short-acting 0.1 units/kg every 2 – 4 hours OR SSI every 4 hours

Bottom Line 

DKA management with a SQ insulin protocol is a reasonable approach for patients with mild to moderate DKA, is supported by the American Diabetes Association [5], and can be particularly helpful in this era of ED boarding and bed shortages.  Give a long-acting insulin dose every 24 hours (or restart the patient’s home long-acting regimen) and short-acting insulin every 2 to 4 hours.  Aggressive IV fluid resuscitation, electrolyte repletion, and treatment of underlying precipitating cause remain additional cornerstones of DKA management.

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A reminder of two validated tools used to determine the need for cervical spine imaging in adult blunt trauma patients.   A recent meta analysis concluded:

“Based on studies, both CCR and NEXUS were sensitive rules that have the potential to reduce unnecessary imaging in cervical spine trauma patients. However, the low specificity and false-positive results of both of these tools indicate that many people will continue to undergo unnecessary imaging after screening of cervical SCI using these tools. In this meta-analysis, CCR appeared to have better screening accuracy.”

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A just released study published in the Lancet gives us guidance on which pediatric blunt trauma patients need cervical spine imaging.  Age range was 0-17 years.

“Out of 22,430 children included in the study, 433 (1.9%) were found to have Cervical spine injury (CSI). The study identified 4 high risk factors for CSI to be used to triage children to CT (12% risk for a cervical spine injury):

1. Glasgow Coma Scale scores of 3-8
2. Unresponsiveness to on the AVPU scale
3. Abnormal airway/breathing/circulation
4. Focal neurologic deficits

In children without high-risk findings, 5 additional findings identified children with intermediate, non-negligible risk of CSI (3.6% risk of a cervical spine injury):

1. Altered mental status
2. Substantial head
3. Substantial torso injury
4. Midline neck pain
5. Midline neck tenderness”

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The Lever test can be used to examine for a torn ACL

May be helpful when examining larger patients

Place patient supine with both knees extended. Examiner places fist below the proximal third of patient’s calf. 

With the other hand, the examiner presses down on the distal third of the patient’s quadriceps.

Positive test: A torn ACL disrupts the lever arm of the lower leg. The heel will not rise. 

Negative test:  An intact ACL allows the lever arm of the lower leg to lift the heel. The heel will rise. 

https://www.facebook.com/Physiotutors/videos/lelli-test-or-lever-sign-to-diagnose-acl-tears/1181462056040391/

More study is needed but reported sensitivities are similar to classic tests such as the anterior drawer or Lachman.

Breastfeeding provides a great nutrition source for infants, but early cessation is common for a wide variety of reasons.  Notably, being asked to withhold breastmilk (“pump and dump”) due to safety concerns or illness increases rates of termination. 

A recent paper is an invaluable reference on commonly used medications in the care of emergency department women of childbearing age and the lactation risk. It breaks down medications into clinical categories and then further highlights those that are safe, likely safe, and safe-but may reduce milk supply, and those to avoid. 

The majority of commonly used medications in the ED are safe to use in breastfeeding.  Only 3% of the medication analyzed should be avoided (aspirin [at doses > 325mg/day], dicyclomine, prochlorperazine, and benzonatate) and in most cases a safe alternative could be used. 

Using these recommendations can help prescribe safe medications, prevent the recommendations to pump and dump, and relieve stress for the patient breastfeeding.

Consider adding the LactMed(R) app to your phone as well - This is a free database through the NIH to search individual medications to assess risk in lactation.

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BACKGROUND:
Cardiac arrest is time sensitive disease. Despite significant advances in resuscitation technology such as eCPR and mechanical compression devices, early basic life support interventions (specifically bystander CPR) are strongly associated with survival. EMS systems must advocate for early initiation of bystander CPR. Dispatch Assisted CPR (DA-CPR) is one of several strategies designed to improve outcomes and encourage early compressions. To optimize survival, EMS systems should achieve a comprehensive understanding about barriers to succesful initiation of DA-CPR. 

METHODS AND OUTCOMES:
49,165 patients with out of hospital cardiac arrest were eligible for inclusion the study, and over 36,000 underwent successful DA-CPR. The study's primary outcome was good neurological recovery at hospital discharge. Secondary outcomes included: prehospital return of spontaneous circulation (ROSC)and survival to hospital discharge. The authors defined successful DA-CPR when bystanders initiated compressions and continued resuscitation until the arrival of EMS. 

RESULTS:
Quite a few results were consistent with prior studies. Unsuccessful DA-CPR was associated with: 

• Advanced patient age (>65 yo) 
• Arrest location in private or non metropolitan place
• Lack of recognition of cardiac arrest 
• Lack of bystander education on cardiopulmonary resuscitation

Successful DA-CPR was more likely associated with the presence of family members at the scene and improved neurological recovery. Witnessed arrests were also more likely to receive successful DA-CPR. Not surpringly, patients in the successful DA-CPR group also exhibited improved survival to discharge and prehospital ROSC. 

BOTTOM LINE:
Though the study is retrospective and involves a host of confounding variables, EMS systems continue to identify modifiable factors linked to the delivery of DA-CPR. Improved community CPR education and dispatcher training may contribute to higher DA-CPR rates. 

BALTIMORE, MD,  SPECIFIC PEARL:
Baltimore metropolitan jurisdictions are collaborating with the CPR LifeLinks program to address DA-CPR. The CPR LifeLinks program a national initiative “to help communities save more lives through implementation of telecommunicator and high performance CPR programs."  https://www.911.gov/projects/cpr-lifelinks/

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We heard it before. Continuous administration of antibiotics might be associated with better outcomes. However, results from smaller randomized controlled trials of beta-lactam showed inconsistent conclusions. Therefore, a large RCT was conducted

Settings: 31 ICUs in Croatia, Italy, Kazakhstan, Russia between June 2018 – August 2022.

Randomized, double-blind control trial.

Participants:

• Patients with sepsis or septic shock who were given meropenem by their clinicians. 
• A total of 607 patients were enrolled: 303 continuous meropenem vs. 304 intermittent administration of meropenem.

Outcome measurement: 

• Primary outcome: all cause mortality at day 28.
• Secondary outcome: emergency of pan-drug resistant bacteria at day 28.

Study Results:

• 369 (61%) had septic shock, while 33% had low respiratory tract infection. There were 442 (73%) had invasive mechanical ventilation. 
• Median SOFA score was 9 [6-11]; the median daily meropenem dose was 0.04 g/kg/day (total of 3 g/day).
• The all cause mortality at 28 days was 91 (30%) for continuous group vs. 99 (33%) (P = 0.50) for intermittent group.
• The rate of emergence of pandrug resistant bacteria was 68/288 (24%) vs. 70/280 (25%) (P= 0.70)

Discussion:

• The current study involved more high risk patients, as the median SOFA was high at 9
• There was no therapeutic monitoring in this study, so the minimal inhibitory concentration was not known.
• Continuous meropenem might be less labor-intensive than intermittent meropenem, which required administration every 8 hours.

Conclusion: 

In critically ill patients with sepsis, continuous administration of meropenem did not improve mortality nor reduce the emergence of pandrug resistant bacteria.

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In a critically ill trauma patient, the FAST exam is used to evaluate for potential internal injuries. Specifically, the subxiphoid view of the FAST exam helps assess for signs of pericardial tamponade. However, distinguishing between a pericardial effusion and an epicardial fat pad can be challenging. 

One study indicated that the sensitivity of EPs in differentiating between effusion and fat pad was 73%, with a specificity of 44% when reviewing difficult patient video clips. 

Here are some tips to help you distinguish between effusion and fat pad: 

Change your view: Use the parasternal long axis view, which is more sensitive for effusion. Fat pads are usually anteriorly, and effusions tend to accumulate posteriorly in a supine patient. 

Screen for other signs of tamponade: Adjust your subxiphoid view to visualize the IVC entering the right atrium, allowing better visualization of the right side of the heart. 

Movement: Fat tends to move synchronously with the heart, whereas hemopericardium moves independently. 

Echogenicity: Fat typically appears brighter on ultrasound, while blood tends to be less echogenic.  

For further learning, refer to the supplemental Material from the referenced articles. 

Blood or Fat? Differentiating Hemopericardium versus Epicardial Fat Using Focused Cardiac Ultrasound - PMC (nih.gov)

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This article from JAMA is targeted at inpatient management of asymptomatic hypertension, however,  it’s a great reminder that “hypertensive urgency” is not an entity. We should be treating the patient and not the numbers. Gradual, out patient lowering of asymptomatic hypertension is the safe and proper way to approach this. Spread the word to your friends in primary care, urgent care, dental, and other office based practices.  
 

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This article serves as a great reminder that our older patients are on a significant amount of medications and many of these medications effect cognition. Cognitively impaired patients are at risk of medication errors. High risk medications in older patients include anticoagulants, opioids, anticholinergics, hypoglycemic/insulin and sedating medications.  The authors found: 

• “In unadjusted analyses and analyses adjusted for a variety of demographic and clinical factors, older adults with cognitive impairment living alone were exposed to a similar number of high-risk medications as those living with others, while at the same time receiving less support from others for medication management.”

It is important to ask how the patient takes (or doesn’t take) their medications as well as other social determinate of health such as living alone.

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Hyperkalemia is less common than hypokalemia in pediatric patients, though it is not uncommon to have hemolysis in patients who receive heel stick lab work. 

The age of the patient is critical to determining the cutoff for hyperkalemia:

• Premature infant 4.0–6.5 mmol/L
• Newborn 3.9–5.9 mmol/L 
• Infant 4.1–5.3 mmol/L 
• Child 3.4–4.7 mmol/L

Typically, levels up 6.0mmol/L are well tolerated in children, unless the shift is rapid. For any child meeting age related hyperkalemia or who have a known lower prior potassium level should receive an ECG. 

Treatment for hyperkalemia is similar to adults 

Calcium Chloride (20mmg/kg - Max 1g) or Calcium Gluconate (0.5ml/kg - Max 20ml) is given for cardiac stability. 

Albuterol can be given based on weight

Insulin and dextrose can be used with extreme caution and close monitoring for hypoglycemia. (Dextrose should be given as D10% in children under 5 years of age, D25% can be used if  > 5 years old)

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Lactational mastitis (inflammation of the breast in individuals who are lactating) affects up to 20% of breastfeeding individuals. It is characterized by localized breast pain with erythema, edema,  and systemic symptoms such as fever/chills and malaise. Supportive treatment measures include the use of NSAIDS, heat and/or ice, and continued feeding or emptying of the breast (stagnant milk can allow for progression of infection). If there is no response to supportive measures within 24 hours, pursuing antibiotic therapy is appropriate.  Staphylococcus and Streptococcus species are common organisms responsible for bacterial mastitis; first-line treatment options include Dicloxacillin 500 mg QID or Cephalexin 500 mg QID for 10-14 days. If there is a concern for MRSA, Clindamycin or Bactrim may be used but are considered second-line. Bactrim should be avoided in breastfeeding individuals with infants <1 month or infants who are jaundiced or premature. 

Complications of mastitis can include early termination of breastfeeding, breast abscess, and systemic infection if untreated. Ultrasound can be used to assess for breast abscess in patients who do not respond appropriately to antibiotics.

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A cut-off of 35mm on CT  scan has been shown to be predictive of which traumatic pneumothoracies require  thoracostomy tube placement vs. safety of observation.  This retrospective study looked at chest X-ray findings to see if there was a similar size cut-off where patients could be safely observed rather than undergo this invasive procedure. They found 38mm was the size over which observation failed. Of note, lactic acidosis and need for supplemental oxygen also predicted the need for chest tube placement  

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POCUS for DVT is a tricky examination. 

• Compression should be performed in transverse orientation.
• A negative exam means that the vein should completely collapse with the same pressure to compress the neighboring artery. 
• Thrombus may not always be visualized.

Exam of positive study on transverse:

Longitudinal Image showing clot: 

In this prospective, observational study of trauma patients with isolated head trauma, 62% of patients developed  post-intubation hypotension. Comparing patients receiving hypertonic saline, vasopressors, crystalloid, or blood those receiving hypertonic saline and vasopressors had less post-intubation hypotension. 

TBI patients who develop hypotension have worse outcomes. This study reminds us the use of vasopressors in trauma patients to maintain blood pressure is appropriate in the correct circumstances.

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The Infectious Disease Society of America in 2023 recommended a single dose of an aminoglycoside for uncomplicated cystitis treatment in those with resistance or other contraindications to first line oral agents who were otherwise well enough to be discharged. This very small study (13 participants) suggest this strategy works for complicated (“male sex, urinary flow obstruction, renal failure or transplantation, urinary retention, or indwelling catheters”) cystitis patients who could otherwise be discharged home.

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What is the best provocative test for the diagnosis of carpal tunnel syndrome?

A 2022 study included 37 observational studies to assess the diagnostic accuracy of these provocative maneuvers.

Meta-analysis totaling 2662 wrists of patients with carpal tunnel syndrome.

Surprisingly, the winner was a test that is less familiar to some of us who were taught the traditional tests such as the Phalen test, Tinel test or the carpal tunnel compression test.

Hand elevation has been known to reproduce the symptoms of carpal tunnel syndrome.

The hand elevation test demonstrated the best clinical performance for the diagnosis of carpal tunnel syndrome.

• This test is the most sensitive for diagnosis.

The beauty of the test is that it is as simple to perform as the name suggests.

Have the patient raise their hands above their head for one minute.

Hands are raised actively and without strain, keeping the elbows and shoulders relatively loose. That’s it!

A positive test reproduces the symptoms of carpal tunnel syndrome

The hand elevation test has a high sensitivity (75%-86%) and specificity (89%-98.5%)

Take home: Consider adding this bedside provocative test as the first screening test for patients with suspected carpal tunnel syndrome

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Free Biostatistics Software Options

EpiCalc 2000 – available for Windows. Capabilities include sample size calculation, inferential statistics (p values, 95% CI), simple stratified analysis, paired and independent analyses. Right clicking allows you to do many things. (http://www.brixtonhealth.com/epicalc.html). I've had the most experience with this one.

Epi Info – supported by CDC. Available for Windows and for hand-held. (https://www.cdc.gov/epiinfo/index.html)

P/S – Power and Sample Size Calculation – available for Mac and Window. Supported by Vanderbilt biostatistics. (https://biostat.app.vumc.org/wiki/Main/PowerSampleSize)

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Participation in meetings is an expected part of most (if not all) of our jobs.  How many of these meetings are necessary?  Could some of the “work” of meetings be accomplished with a few emails or other asynchronous forms of communication?  Are meetings cluttering your schedule and making it impossible to get any real work done?

Some answers to these questions are offered in a Harvard Business Review article from March 2022.  

Key points include:

• 70% of all meetings keep employees from working and completing all their tasks.
• Ineffective meetings that waste our time can negatively impact psychological, physical, and mental wellbeing.

Advantages to fewer meetings:

• Productivity was 71% higher when meetings were reduced by 40%.
• Employees feel empowered and more autonomous, increasing their job satisfaction by 52%.
• Removing 60% of meetings increased cooperation by 55%.

Authors recommend holding meetings only when “absolutely” necessary. That typically includes:

• To review work that’s occurred (what worked or didn’t and why)
• To clarify and validate something (policies, team goals, etc.)
• To distribute work appropriately among your team

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