UMEM Educational Pearls

Alcohol withdrawal syndrome is frequently treated with benzodiazepines following CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol scale). There are other medications that are used as either second line or as adjunctive agents along with benzodiazepines. A retrospective study compared the clinical outcomes between phenobarbital vs. benzodiazepines-based CIWA-Ar protocol to treat AWS. 

The primary was ICU length of stay (LOS); secondary outcome were hospital LOS, intubation, and use of adjunctive pharmacotherapy.

Study sample: 60 received phenobarbital and 60 received lorazepam per CIWA-Ar.

Phenobarbital protocol:

• Active DT: 260 mg IV x 1 dose -> 97.2 mg PO TID x 6 doses -> 64.8 mg PO TID x 6 doses -> 32.4 mg PO TID x 6 doses
• History of DT: 97.2 mg PO TID x 6 doses -> 64.8 mg PO TID x 6 doses -> 32.4 mg PO TID x 6 doses
• No history of DT: 64.8 mg PO TID x 6 dose -> 32.4 mg PO TID x 6 doses.

Results

Conclusion

Phenobarbital therapy appears to be a promising alternative therapy for AWS. However, additional studies are needed prior to adapting phenobarbital as first line agent for AWS management. 

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Diplopia can be a challenging complaint to address in the ED. Although not all patients will require imaging, use the simplified table below to help guide the imaging study needed:

C.N.: cranial nerve

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A few (out of 10) tips for the care of sick patients with liver failure:

• Use of albumin is indicated to improve outcomes in spontaneous bacterial peritonitis (SBP), large-volume paracentesis, and hepatorenal syndrome (HRS).

• Norepinephrine remains the vasopressor of choice for nonhemorrhagic shock. Use vasopressin or terlipressin (outside the U.S.) in AKI due to HRS to maintain a target MAP and for splanchnic vasoconstriction.

• INR does not correctly reflect coagulation performance. Platelet count and fibrinogen are the best predictors of bleeding, and thromboelastography (via TEG/ROTEM) can reduce blood products administered for hemorrhage without affecting mortality.

• If a nasogastric tube is indicated (administration of lactulose, decompression of SBO, etcetera), presence of [non-recently banded] esophageal varices is not a contraindication.

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Coins are the most commonly ingested foreign body in the pediatric age group with a peak occurrence in children less than 5 years old.  X-rays are considered the gold standard for definitive diagnosis and location of metallic foreign bodies.  This study aimed to find a way to decrease radiation exposure by using a metal detector.

19 patients ages 10 months to 14 years with 20 esophageal coins were enrolled in the study.  All proximal esophageal coins were detected by the metal detector.  5 patient's failed initial detection of the coin with the metal detector and all of those patients had the coin in the mid or distal esophagus with a depth greater than 7 cm from the skin.

Bottom line: A metal detector may detect proximal esophageal coins.  This may have a role in decreasing repeat x-rays.

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• The Canadian C-Spine Rule (CCR) has been shown to decrease the use of cervical spine imaging in low-risk trauma patients.
• While developed for use by physicians, CCR has also been validated in ED triage nurses with moderate interrater reliability (kappa 0.78) by Stiell et al. in 2010.
• Stiell’s group has since implemented the use of CCR by ED triage nurses at 9 teaching hospitals in Ontario with a combined annual volume of approximately 670,000 ED visits.
• 180 certified nurses evaluated 1408 patients.
  • 806 (57.2%) arrived with c-spine immobilization.
  • 602 (42.8%) had neck pain but no immobilization.
• Overall, nurses removed immobilization in 331 (41.4%) patients and applied immobilization in 203 (14.4%) patients.
• Diagnostic imaging was performed in 612 (43.4%) patients and found 16 (1.1%) clinically important and 3 (0.6%) clinically unimportant injuries.
• There were no missed c-spine injuries to the knowledge of the authors as the study hospitals were closely connected with the regional spine centers.
• Time from nursing assessment to discharge decreased by 26.0% (3.4h vs. 4.6h)

Bottom Line: ED triage nurses can safely use the Canadian C-Spine Rule.  This approach can improve patient care and decrease length of stay in the ED.

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Identifying Critically Ill Cancer Patients in the ED

• Immunosuppressed patients with malignancy are at high risk of complications and rapid decompensation.
• Select pearls in identifying ED patients with cancer that are at high risk of critical illness include:
  • Patients with profound neutropenia (< 100/mm³) are at high risk for fungal infections (i.e., aspergillosis)
  • Hypoxemia that requires oxygen is a predictor of later ICU admission.
  • Patients with bilateral infiltrates on CXR are at high risk of decompensation. Consider ICU admission.
  • Patients with promyelocytic leukemias are at high risk of DIC. Patients with this complication should be admitted to the ICU.

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In which age groups should children with Sport Related Concussion be managed differently from adults?

• Not adequately addressed in literature.
• Consider 5-12 years old vs 13 and over for child vs. adult testing

Are there targeted subgroups who would benefit from closer outpatient and specialty follow-up?

Predictors of Prolonged Recovery in Children
 

• Female sex
• physician diagnosis of migraine
• Prior concussion with symptoms lasting longer than 1 weeks
• Multiple concussions
• ADHD/LD/Mood disorders
• Acute headache
• Age 13 or older
  • Teenage and high school years represents the greatest age period for prolonged recovery
• Prior
• Dizziness
• Sensitivity to noise
• Fatigue
• Answering questions slowly
• 4 or more errors on BESS testing

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The management of pediatric hydrocarbon ingestion has not changed significantly over the past several decades. One of the earlier study that helped established the management approach is by Anas N et al. published in JAMA, 1981.

It was a retrospective study of 950 children who ingested household hydrocarbon containing products.

Discharged patients: n=800

• They asymptomatic at their initial presentation and after 6-8 hours of observation.
• All had normal CXR

Admitted patients: n=150

• 79 symptomatic patients at the time of initial evaluation with abnormal CXR.
• 71 patients were asymptomatic but CXR showed pulmonary involvement/pneumonitis or had pulmonary symptoms prior to hospital presentation
• 7 symptomatic patients developed pneumonia

This study recommended that hospitalization is required in patients…

1. Who are symptomatic at the time of initial evaluation
2. Who become symptomatic during the 6-8 hour observation period.

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The most recent AHA guidelines for goal blood pressure after return of spontaneous circulation (ROSC) post-cardiac arrest recommend a definite mean arterial pressure (MAP) goal of > 65 mmHg.¹ There is no definitive data to recommend a higher specific goal, but there is some evidence to indicate that maintaining higher MAPs may be associated with better neurologic outcomes.²

A recently published prospective, observational, multicenter cohort study looked at neurologic outcomes corresponding to different MAPs maintained in the initial 6 hours post-cardiac arrest.³

Findings: 

1. Compared to lower blood pressures (MAPs 70-90 mmHg), the cohort with MAPs > 90 mmHg had:

• a higher rate of good neurologic function at hospital discharge (42 vs.15%, p < 0.001)
• a higher rate of survival to 72 hours (86 vs. 74%, p=0.01) and hospital discharge (57 vs 28%, p < 0.001)

2. The association between MAP > 90 mmHg and good neurologic outcome was stronger among patients with a previous diagnosis of hypertension, and persisted regardless of initial rhythm, use of vasopressors, or whether the cardiac arrest occured in or out of hospital.

3. There was a dose-response increase in probability of good neurologic outcome among all MAP ranges above 90 mmHg, with MAP >110 mmHg having the strongest association with good neurologic outcome at hospital discharge.

Note: The results of a separate trial, the Neuroprotect post-CA trial, comparing MAPs 85-100 mmHg to the currently recommended MAP goal of >65 mmHg, are pending.⁴

Bottom Line: As per current AHA guidelines, actively avoid hypotension, and consider use of vasopressor if needed to maintain MAPs > 90 mmHg in your comatose patients post-cardiac arrest, especially those with a preexisting diagnosis of hypertension.

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The most common methods of medication administration in the emergency department are oral, intravenous (IV), and intramuscular (IM).  If the oral route is not available, if IV/IM are not necessary, or if obtaining IV access is challenging, intranasal (IN) medication delivery is a reasonable alternative.  More concentrated products are preferred and a volume of 1 mL or less per nostril should be utilized.  Below is a table of the commonly used medications used via the IN route. 

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Concussion Management in Children

What are the predictors of prolonged recovery of concussion in children?

Female sex, age greater than 13, prior physician diagnosis of migraine, prior concussion with symptoms lasting longer than 1 week, history of multiple concussions, headache, sensitivity to noise, dizziness, fatigue, answering questions slowly and four or more errors on tandem stance testing.

Age:  As compared to younger children, adolescents have a greater number of and more severe postconcussive symptoms. They take longer to recover and return to school and sport.

Subjects: Math tends to pose greater problems followed by reading/language, arts, sciences and social studies.

Computer testing:  The widespread use of computer neuropsychological testing is not recommended in children and adolescents. This is due to issues with reliability over time and insufficient evidence of both diagnostic and prognostic value. When used, reference to normative data should be done with caution. Testing should also NOT be used in isolation in concussion diagnosis and management.

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Manifestations due to neurosyphilis present as one of 3 categories: stroke due to arteritis, masses in the brain (granulomata), and chronic meningitis.

Although serum VDRL/TPPA tests will be positive in almost all patients, it’s important to remember that the diagnosis requires the presence of ALL of the following criteria:

1. positive treponemal (e.g. FTA-ABS, TP-PA) AND nontreponemal (e.g. VDRL, RPR) serum test results

2. positive CSF VDRL OR positive CSF FTA-ABS test result 

3. one CSF laboratory test abnormality, such as pleocytosis (cell count >20/μL) or high protein level (>0.5 g/L)

4. clinical symptoms

This is important because the treatment of neurosyphilis is distinctly different from other forms, as it requires admission for IV antibiotics for at least 10 days.  

Bonus Pearl: CSF RPR is unreliable as it is more likely to be falsely positive than other specific CSF testing.

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• High-quality CT is adequate for clearing c-collar in obtunded patients.
• A follow-up exam before discharging the patient strengthens your decision making and documentation.
• MRI can be reserved for high-risk patients, patients who are being admitted to surgical critical care units, and those who have residual findings once alert.

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Historically, the C-reactive protein (CRP) has been used in the assessment of the febrile child and is the only biomarker recommended by the National Institute for Health and Care Excellence (NICE).

CRP increases 4-6 hours after the onset of inflammation, doubling every 8 hours and peaking at 36-50 hours.  It rapidly decreases once the inflammation has resolved.

An elevated CRP alone is not conclusive of a serious bacterial infection (SBI).

A CRP >75 mg/L increased the relative risk of SBI by 5.4.

A CRP <20 mg/L decreased the risk of SBI, but there was still a small subset of children where SBI was present.

In infants < 3 months initial CRP measurements are poorly accurate, but when trended may be useful in deciding when to stop antibiotics (rather then when to start them).  A normalizing CRP demonstrated a 100% negative predictive value for excluding invasive bacterial infection.

Bottom line:

CRP is not a rule in/rule out test

CRP is not helpful in diagnosing SBI, but serial measurements may be useful in monitoring response to treatment

CRP has a limited role in well appearing children older than 3 months

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• History of regular cannabis use at least weekly for any duration of time.
• Compulsive hot water bathing multiple times per day for symptom relief which is mediated by the TRPV capsaicin receptors.
• Resolution of symptoms with cannabis cessation.
• Prior nonrevealing extensive diagnostic work up.

CHS Treatment:

• Definitive and most effective treatment is to stop cannabinoid use which provides complete relief within 7–10 days.
• Temporary relief occurs with hot water bathing, Capsaicin topical cream, Haldol administration, and fluid resuscitation.

Bottom line: Patient education should be provided on the paradoxical and recurrent nature of the symptoms of CHS to discourage relapse of use often stemming from false preception of beneficial effects of cannabis on nausea. 

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You have successfully diagnosed a concussion, explained everything to the parents, closed the encounter, reached for the doorknob and….

“What about school?”

An athlete should not return to play until they have successfully returned to school

Several studies have demonstrated that intense cognitive stimulation and intense intellectual stimulation result in worsening symptoms

                -school work, TV, videogames, texting

Attempt to limit cognitive activity to the point where it begins to reproduce or worsen symptoms!

Step 1: 24 to 48 hours of rest

Step 2: Daily at home activities that do not increase symptoms. Starting with 5 – 10 minutes and gradually build up to a goal of tolerating 30 minutes of cognitive activity without worsening symptoms.

                Home work, reading assignments, other cognitive activities

Step 3: Attempt Return to school (will not be completely symptoms free!) with either part time, partial days, or with extended breaks. Goal of tolerating an entire school day without symptoms.

Most students recover fully within 4 weeks and adjustments can then be discontinued. Others with ongoing symptoms may require ongoing academic modifications (extra time for tests, papers, etc).

Suggested examples of adjustments:  Shortened days, 15 minute break for every 30 minutes of instruction, providing class notes, tutoring, decreasing course expectations, decreasing exposure to classes which exacerbate symptoms, no computer work, untimed tests and quizzes, lunch in a quiet place.

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Does using a combination of aspirin and clopidogrel decrease your patient’s risk of recurrent stroke after a minor ischemic stroke or high risk TIA event?

• The recent international Platelet-Oriented Inhibition in New TIA and Minor Stroke (POINT) trial compared 4881 patients receiving aspirin/clopidogrel vs. aspirin/placebo within 12 hours of symptom onset.
  • Patients who received DAPT had a lower rate of major ischemic events at 90 days compared to aspirin/placebo (5.0% vs. 6.5%, p=0.02).
  • However, patients who received DAPT had a higher rate of major hemorrhage compared to aspirin/placebo (0.9% vs. 0.4%, p=0.02).
• A similar Chinese study, the Clopidogrel in High-Risk Patients with Acute Nondisabling Cerebrovascular Events (CHANCE) trial, compared 5170 patients receiving DAPT vs. aspirin/placebo within 24 hours also found lower rate of stroke (8.2% vs. 11.7%, p<0.001) but similar rates of moderate/severe hemorrhage (0.3% vs. 0.3%, p=0.73).
• Major differences between these two trials are the population studied and the duration of DAPT, as POINT utilized DAPT for 90 days while CHANCE utilized DAPT for 21 days.

Bottom Line: The use of DAPT in minor ischemic stroke and high risk TIA reduces the risk of recurrent stroke.  However, the duration of DAPT may affect the risk of major hemorrhage.

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We know that high flow nasal cannula is an option in the management of acute hypoxic respiratory failure without hypercapnea. A newer iteration of high flow, "high velocity nasal insufflation" (HVNI), may be up-and-coming.

According to its makers (Vapotherm), it is reported to work mainly by using smaller bore nasal cannulae that deliver the same flows at higher velocities, thereby more rapidly and repeatedly clearing dead space, facilitating gas exchange and potentially offering ventilatory support. 

In an industry-sponsored non-inferiority study published earlier this year:

• 204 adult patients in 5 EDs
• Any acute respiratory failure deemed by the treating physician to require non-invasive positive pressure ventilation (NPPV)
• Patients randomized to either NPPV (bilevel positive airway pressure) or HVNI
• Rate of HVNI treatment failure (26%) and intubation @ 72 hours (7%) fell within predefined noninferiority margins
• Rates of PCO2 clearance were similar between HVNI and NPPV groups
• The study was not powered to detect differences between different etiologies for respiratory failure
• Authors concluded that HVNI is noninferior to NPPV for all-comer respiratory failure.

Bottom Line: 

The availability of a nasal cannula that helps with CO2 clearance would be great, and an option for patients who can't tolerate the face-mask of NPPV would be even better.

HVNI requires more investigation with better studies and external validation before it can really be considered noninferior to NPPV, but it certainly is interesting. 

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Clonidine is an alpha-2 agonist commonly used to treat hypertension. Clonidine can also be used to mitigate symptoms of opioid withdrawal as it easily crosses the blood brain barrier and reduces sympathetic effects.

When using clonidine for acute withdrawal or blood pressure control, oral tablets are the preferred route.  Clonidine transdermal patches have slow absorption and take 2-3 days for the effect to be seen.  Once removed, clonidine patches can provide therapeutic levels for up to 20 hours.

Bottom Line: If clonidine is needed acutely for your patient, select oral tablets and titrate to effect.

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