Category: Toxicology
Keywords: Botulinum, Dimethylmercury, VX, Tetrodotoxin (PubMed Search)
Posted: 8/17/2017 by Kathy Prybys, MD
(Updated: 8/31/2017)
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VX ("venomous agent X")
LD50 expresses the dose at which 50% of exposed population will die as a result of exposure.
Category: Critical Care
Keywords: Mechanical ventilation, sedation (PubMed Search)
Posted: 8/30/2017 by Kami Windsor, MD
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Background: Sedation and analgesia are key components for mechanically ventilated patients. While significant data exists regarding how to manage sedation and analgesia in the ICU setting, very little data exists on management in the ED.
Data: A prospective, single-center, observational study of mechanically-ventilated adult patients used linear regression to identify ED sedation practices and outcomes, with a focus on sedation characteristics using the Richmond Agitation-Sedation Scale (RASS).
Findings:
Bottom line: Avoid early deep sedation in your intubated patients as this may be directly associated with increased mortality. Instead, a goal RASS of 0 to -2 should be appropriate for most non-paralyzed, mechanically-ventilated ED patients, extrapoloating from ICU guidelines.
Stephens, R.J., et al., Analgosedation Practices and the Impact of Sedation Depth on Clinical Outcomes Among Patients Requiring Mechanical Ventilation in the ED: A Cohort Study. Chest, 2017 [Epub ahead of print].
Barr J, Fraser GL, Puntillo K, Ely EW, Gélinas C, Dasta JF, Davidson JE, Devlin JW, Kress JP, Joffe AM, et al.; American College of Critical Care Medicine. Clinical practice guidelines for the management of pain, agitation, and delirium in adult patients in the intensive care unit. Crit Care Med 2013;41:263–306.
Category: Orthopedics
Keywords: Concussion recovery (PubMed Search)
Posted: 8/26/2017 by Brian Corwell, MD
(Updated: 11/27/2024)
Click here to contact Brian Corwell, MD
There is tremendous interest in identifying factors that may influence outcome from sports related concussion.
The strongest predictor of slower recovery is the severity of symptoms in the 1-2 days post injury
-Fewer Sx's in this time period predict a quicker recovery
Pre injury history of mental health problems, depression or migraine headaches predict a longer recovery course
Teenagers might be more vulnerable to having persistent symptoms with greater risk for girls than boys
Having a prior concussion is a risk for having a future concussion
The large majority of injured athletes recover from a clinical perspective within the first month of injury many within the first 10 days
McCrory P et al. Br J Sports Med 2017;51:838-847.
Category: Pediatrics
Keywords: allergic reaction, anaphylaxis, auto-injector, epi-pen (PubMed Search)
Posted: 1/27/2017 by Mimi Lu, MD
(Updated: 8/25/2017)
Click here to contact Mimi Lu, MD
Anaphylaxis is a life threatening emergency with mortality of up to 2% [1]. Early recognition is imperative and administration of timely Epinephrine is the single most important intervention [2]. While providers may be hesitant to administer epinephrine in older patients due to fear of precipitating adverse cardiovascular events, they may also hesitate in younger patients due to fear of overdose.
Iimmediate administration with any dose available is recommended because:
Bottom line:
There are no absolute contraindications (including age) for epinephrine in patients with anaphylaxis. Give the initial dose IM into the anterolateral thigh.
1- Bock SA, Muñoz-Furlong A, Sampson HA. Fatalities due to anaphylactic reactions to foods. J Allergy Clin Immunol. 2001 Jan. 107(1):191-3. [Medline].
4- Wood JP, Traub SJ, Lipinski C. Safety of epinephrine for anaphylaxis in the emergency setting. World Journal of Emergency Medicine. 2013;4(4):245-251. doi:10.5847/wjem.j.issn.1920-
Category: Toxicology
Keywords: dabigatran reversal, Idarucizumab (PubMed Search)
Posted: 8/25/2017 by Hong Kim, MD
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Full cohort analysis idarucizumab for dabigatran associated bleeding was recently published in NEJM.
This study evaluated the laboratory correction of elevated ecarin clotting time or diluted thrombin time induced by dabigatran and time to either cessation of bleeding (Group A: patients with GI bleeding, traumatic bleeding, or ICH) or time to surgery (Group B: patients requiring surgical intervention within 8 hours).
Findings
Group A (n=301): Median time to the cessation of bleeding was 2.5 hours in 134 patients.
HOWEVER:
Group B (n=202): Median time to intended surgery after infusion of idarucizumab was 1.6 hours.
Laboratory markers:
100% reversal of abnormal ecarin clotting time or diluted thrombin time within 4 hours after the administration
Mortality
Conclusion
Authors concluded thate idaurcizumab is an "effective" reversal agent for dabigatran.
Overall, the findings are more promising compared to the interim analysis that was published in 2015.
Other findings:
Infusion of idarucizumab decreased the dabigatran level from 110 ng/mL (Group A) and 73.6 ng/mL (Group B) to < 20 ng/mL.
Rebound levels of > 20 ng/mL were noted in 191 patients after 12 – 24 hours after idarucizumab adminiatration
Thrombotic events occured in 24 patients (14 in Group A and 10 in Group B) within 30 days after treatment
Serious adverse events occured in 23.3% of the patients within 5 days.
Most frequent events were:
Pollack CV et al. Idarucizumab for dabigatran reversal - full cohort analysis. N Eng J Med 2017;377:431-41.
Category: Neurology
Keywords: meningitis, CSF, glucose, glucometer (PubMed Search)
Posted: 8/24/2017 by WanTsu Wendy Chang, MD
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Category: Critical Care
Posted: 8/22/2017 by Mike Winters, MBA, MD
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Hyponatremic Encephalopathy
Archinger SG, Ayus JC. Treatment of hyponatremic encephalopathy in the critically ill. Crit Care Med. 2017; epub ahead of print.
Category: Pediatrics
Keywords: Febrile seizure, meningitis (PubMed Search)
Posted: 8/18/2017 by Jenny Guyther, MD
(Updated: 11/27/2024)
Click here to contact Jenny Guyther, MD
Febrile seizures occur in children 6 months through 5 year olds. A complex febrile seizure occurs when the seizure is focal, prolonged (> 15 min), or occurs more than once in 24 hours.
The prevalence of bacterial meningitis in children with fever and seizure after the H flu and Strep pneumomoniae vaccine was introduced is 0.6% to 0.8%. The prevalence of bacterial meningitis is 5x higher after a complex than simple seizure.
From the study referenced, those children with complex febrile seizures who had meningitis all had clinical exam findings suggestive of meningitis. More studies are needed to provide definitive guidelines about when lumbar punctures are needed in these patients.
This study was a retrospective review of children aged 6 months to 5 years who had complex febrile seizures in France between 2007-2011.
Children were excluded if they had a simple febrile seizure, history of non-febrile seizure, conditions associated with a higher risk of seizure (cerebral malformations, genetic syndrome, trauma in the previous 24 hours) or predisposing to bacterial meningitis (sickle cell, cancer, immunosuppressive treatments). Outcomes were the diagnosis of bacterial or HSV meningitis at 7 days
The rate of bacterial meningitis was 0.7% (CI 0.2-1.6). There were no cases of HSV meningitis.
69% of the study patients did not have a lumbar puncture, however, follow up was done by repeat exam, phone and review of the meningitis and also death registry if the patient was lost to follow up.
The clinical exam in the 5 children with bacterial meningitis was suggestive of meningitis (irritability, altered mental status, bulging fontanel). In a subgroup of patients without physical exam findings suggestive of meningitis, there were no cases of bacterial meningitis.
Guedji R et al. Do All Children Who Present With a Complex Febrile Seizure Need a Lumbar Puncture? Annals of Emergency Medicine. 2017; 70 (1):52-62.
Category: International EM
Keywords: suicide, clinical policies, risk-assessment tools (PubMed Search)
Posted: 8/11/2017 by Jon Mark Hirshon, PhD, MPH, MD
(Updated: 8/16/2017)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD
In patients presenting to the ED with suicidal ideation, physicians should not use currently available risk-assessment tools in isolation to identify low-risk patients who are safe for discharge. The best approach to determine risk is an appropriate psychiatric assessment and good clinical judgment, taking patient, family, and community factors into account. (Level C Recommendation, based upon the quality of the research.)
As noted in a previous Pearl (see August 2, 2017), the American College of Emergency Physicians recently published a methodological rigorous clinical policy entitled “Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department.”
Another question addressed within the document was the following: “In the adult patient presenting to the ED with suicidal ideation, can risk-assessment tools in the ED identify those who are safe for discharge?”
They determined that in patients presenting to the ED with suicidal ideation, physicians should not use currently available risk-assessment tools in isolation to identify low-risk patients who are safe for discharge. The best approach to determine risk is an appropriate psychiatric assessment and good clinical judgment, taking patient, family, and community factors into account. (Level C Recommendation, based upon the quality of the research.)
http://www.annemergmed.com/article/S0196-0644(17)30070-7/fulltext
Category: Critical Care
Keywords: autoimmune, rheumatology, thrombosis, hematology (PubMed Search)
Posted: 8/15/2017 by Kami Windsor, MD
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Catastrophic Antiphospholipid Syndrome (CAPS):
A life-threatening “thrombotic storm” of multi-organ micro & macro thrombosis in patients with antiphospholipid syndrome (known or unknown).
Triggered circulating antibodies (usually by infection, but can be prompted by malignancy, pregnancy, and lupus itself) cause endothelial disruption and inflammation leading to prothrombotic state, commonly with SIRS response.
Mortality is high at an estimated 40%.
Confirm diagnosis with antiphospholipid antibody titers.
Treat ASAP with unfractionated heparin, corticosteroids, and Hematology consultation for plasma exchange and/or IVIG.
Kazzaz NM, McCune WJ, Knight JS. Treatment of catastrophic antiphospholipid syndrome. Curr Opin Rheumatol. 2016;28(3):218-27.
Cervera R, Rodriguez-Pinto I, Colafrancesco S, et al. 14th International Congress on Antiphospholipid Antibodies Task Force. Report on catastrophic antiphospholipid syndrome. Autoimmun Rev 2014; 13:699–707.
Category: Neurology
Keywords: pituitary apoplexy, subarachnoid hemorrhage, meningitis, headache, CT, MRI (PubMed Search)
Posted: 8/9/2017 by Danya Khoujah, MBBS
(Updated: 11/27/2024)
Click here to contact Danya Khoujah, MBBS
Bottomline: Keep pituitary apoplexy in your differential when considering SAH or meningitis, especially in the presence of risk factors, and have a low threshold to order an MRI.
Category: Gastrointestional
Keywords: Gastroparesis, haloperidol (PubMed Search)
Posted: 8/5/2017 by Ashley Martinelli
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Take Home Point: In patients with diabetic gastroparesis, haloperidol may be an effective adjunctive treatment to prevent hospitalizations and reduce opioid requirements.
In Depth:
Study Design: single-center, retrospective review, case-matched to prior visit for gastroparesis
Patients:
52 patients with previously diagnosed diabetic gastroparesis by gastric motility study who presented to the ED for gastroparesis treatment
Groups:
Haloperidol administered visit
Haloperidol NOT administered visit (most recent visit, >7 days prior to haloperidol visit)
Results:
Baseline characteristics: median age 32 (21-57), 62% (32/52) female
Statistically significant reduction in hospital admissions for the haloperidol visit: (5/52 [10%] [CI 3-21%]) vs the non-haloperidol visit (14/52 [27%] [CI 16-41%]) p=0.02
Statistically significant reduction in opioid administration during the haloperidol visit: 6.75 ME (IQR 7.93) vs 10.75 ME (IQR 12) p=0.009
No difference in ED LOS, hospital LOS or need for additional antiemetics/prokinetics
No dystonic reactions, akathesia, excessive sedation, or cardiovascular complications in patients who received haloperidol
Limitations:
Small, single-center, retrospective study that only included patients with diabetic gastroparesis
Only intramuscular administration was studied
Baseline QT not reported
Young patient population, no description of comorbidities or home medications
Conclusions:
Haloperidol may be considered as an adjunctive therapy in patients with diabetic gastroparesis for its antiemetic and analgesic properties. Prospective studies are necessary to confirm findings.
Ramirez R, Salcup P, Croft B, Darracq MA. Am J Emerg Med 2017;35:1118-1120.
Category: International EM
Keywords: Mental health, routine laboratory test, acute psychiatric patient (PubMed Search)
Posted: 8/2/2017 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD
Patients with psychiatric disorders are found globally, with a recent global burden of disease estimate that mental illness accounted for 32.4% of years lived with disability and 13.0% of disability-adjusted life-years.
The American College of Emergency Physicians just published a methodological rigorous clinical policy entitled “Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department.”
One question they sought to answer was “In the alert adult patient presenting to the ED with acute psychiatric symptoms, should routine laboratory tests be used to identify contributory medical conditions (nonpsychiatric disorders)?”
Their assessment was: “Do not routinely order laboratory testing on patients with acute psychiatric symptoms. Use medical history, previous psychiatric diagnoses, and physician examination to guide testing.” This was a Level C recommendation, based upon the quality of the research.
Bottom Line: Current literature does not support routinely ordering laboratory testing on patients with acute psychiatric symptoms. However, the quality of the evidence was not strong and local clinical context should be considered.
http://www.thelancet.com/journals/lanpsy/article/PIIS2215-0366(15)00505-2/abstractege of
http://www.annemergmed.com/article/S0196-0644(17)30070-7/fulltext
Category: Critical Care
Keywords: RV dysfunction, APRV, echo, ultrasound (PubMed Search)
Posted: 8/1/2017 by Daniel Haase, MD
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--RV systolic function is negatively affected by high RV afterload
--High mean airway pressures on the ventilator (particularly in modes such as APRV [airway pressure release ventilation]) can induce RV dysfunction
*****CLICK BELOW FOR A GREAT CASE!!!*****
A 25yoF with ARDS is on APRV (36/0 and 5/0.5). She is on norepi to maintain a MAP >65. A bedside echo reveals a dilated, dysfunctional RV.
--Open "A4C end diastole"
Measurement of TAPSE confirms the RV dysfunction, but also reveals the cause.
--Open "TAPSE"
Every 5th beat, the TAPSE significantly improves to "normal" range. The four beats inbetween are abnormal. The 5th normal beat coincides with the APRV relase, when airway pressures are zero! Thus, this change in RV function is from the ventilator alone. The TAPSE decreases by almost 40%!
--Open "TAPSE measured"
Be careful with high mean airway pressures in patients with known or suspected RV dysfunction. This is why we try to avoid intubation in HD significant pulmonary embolism!
Category: Pediatrics
Posted: 7/29/2017 by Mimi Lu, MD
Click here to contact Mimi Lu, MD
The answer appears to be ... it depends.
Early Oseltamivir Treatment in Influenza in Children1-3 Years of Age: A Randomized Controlled Trial
A study in 2010 out of Finland by Heinonen, et al showed that if given in the first 12 hours of symptom onset to otherwise healthy pediatric patients between the age of 1-3 years:
- decrease incidence of acute otitis media by 85%
- no difference if given within 24 hours
Among children with influenza A, oseltamivir started within 24 hours of symptom onset
- shortened medium time to resolution of illness by 3.5 days (3.0 versus 6.5) in all children
- shortened median time to resolution of illness by 4.0 days in UNvaccinated children
- Reduced parental work absenteeism by 3 days
* no differences were seen in children with influenza B *
Limitations***
- Single Center study in Finland
- The authors received support from the drug manufacturer
- The sample size of children with confirmed influenza cases with small (influenza A: 79, influenza B: 19)
Takeaway:
If you have a patient between the age of 1-3 years with very early symptoms concerning for flu, a positive rapid influenza A test could allow you to cut her symptoms by 3 days, prevent complications, and allow parents to go back to work sooner.
Heinonen S, Silvennoinen H, Lehtinen et al. Early oseltamivir treatment of influenza in children 1-3 years of age: A randomized controlled trial. Clin Infect Dis. 2010;51(8):87-94.
Category: Toxicology
Keywords: salicylate poisoning, endotracheal intubation, hemodialysis (PubMed Search)
Posted: 7/27/2017 by Hong Kim, MD
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Patients with severe salicylate poisoning may require endotracheal intubation due to fatigue from hyperventilation or mental status change.
A previously published study (Stolbach et al. 2008) showed that mechanical ventilation increases the risk of acidemia and clinical deterioration.
A small retrospective study investigated the impact of hemodialysis (HD) in intubated patients with salicylate poisoning.
Findings:
53 cases with overall survival rate of 73.2%
In patients with salicylate level > 50 mg/dL
If salicylate level > 80 mg/dL
Bottom Line:
There is moratality benefit of HD in intubated salicylate-poisoned patient.
McCabe DJ, Lu JJ. The association of hemodialysis and survival in intuated salicylate-poisoned patients. Amer J Emerg Med 2017;35:899-903.
Stolbach QI, Hoffman RS, Nelson LS. Mechanical ventilation was associated with acidemia in a case series of salicylate-poisoned patients. Acad Emerge Med 2008;15;866-869.
Category: Critical Care
Posted: 7/25/2017 by Mike Winters, MBA, MD
(Updated: 11/27/2024)
Click here to contact Mike Winters, MBA, MD
Improving Resuscitation Performance
Lauria M, et al. Psychological skills to improve emergency care providers' performance under stress. Ann Emerg Med. 2017; epub ahead of print.
Category: Orthopedics
Keywords: Knee instability (PubMed Search)
Posted: 7/23/2017 by Brian Corwell, MD
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PCL injuries can sometimes have involvement of the posterolateral corner (PLC)
The dial test can be used to diagnose posterior lateral instability and help differentiate it from isolated PCL injuries
The dial test involves comparing the amount of external rotation of the lower leg at the knee while the knees are in 30° and in 90° of knee flexion.
https://www.youtube.com/watch?v=rnk62Y-nDSQ
An isolated injury to the posterolateral corner will result in more than 10° of external rotation in the injured knee that is present at 30° but not at 90° of knee flexion.
http://www.kneejointsurgery.com/wp-content/uploads/2015/06/DIAL-TEST.jpg
http://www.kneejointsurgery.com/wp-content/uploads/2015/06/DIAL-TEST-90.jpg
http://www.kneejointsurgery.com/ligament-injuries/posterolateral-corner/
Category: Pediatrics
Keywords: CT scans, radiation exposure, pediatrics (PubMed Search)
Posted: 7/21/2017 by Jenny Guyther, MD
(Updated: 11/27/2024)
Click here to contact Jenny Guyther, MD
Ventricular shunt (VP) malfunction can be severe and life-threatening and evaluation has typically included a dry CT brain and a shunt series which includes multiple x-rays of the skull, neck, chest and abdomen. The goal of this study was to decrease the amount of radiation used in the evaluation of these patients since these patients will likely present many times over their lifetime. Several institutions have more towards a rapid cranial MRI, however, this modality may not be readily available.
This multidisciplinary team decreased the CT scan radiation dose from 250mA (the reference mA in the pediatric protocol at this institution) to 150 mA which allows for a balance between reducing radiation exposure and adequate visualization of the ventricular system. They also added single view chest and abdominal x-rays.
The authors found that after implementing this new protocol, there was a reduction in CT radiation doses and number of x-rays ordered with no change in the return rate.
Marchese et al. Reduced Radiation in children presenting to the ED with Suspected Ventricular Shunt Complication. Pediatrics. 2017; 139 (5).
Category: Toxicology
Keywords: Vaginal pearls, intravaginal foreign bodies (PubMed Search)
Posted: 7/20/2017 by Kathy Prybys, MD
(Updated: 7/21/2017)
Click here to contact Kathy Prybys, MD
Vaginal douching is a common and potentially dangerous practice. Women engage in this practice predominately for personal hygiene reasons but also with the false belief it will prevent or treat infections and for contraception. Numerous public health agencies and medical societies discourage douching as it has been associated with many adverse outcomes including pelvic inflammatory disease, bacterial vaginosis, cervical cancer, low birth weight, preterm birth, human immunodeficiency virus transmission, sexually transmitted diseases, ectopic pregnancy, recurrent vulvovaginal candidiasis, and infertility.
An increasing fad is the use of intravaginal detox products. Claiming to enhance female health by removing toxins, these mesh cloth-covered balls containing herbs such as mothersworth, osthol, angelica, borneol, and rhizoma, not FDA-approved, are inserted into the vagina for 3 days. Clinical experience demonstrates these products decompose into numerous pieces which become scattered retained intravaginal foreign bodies, cause mucosal irritation, and thereotically could serve as a nidus for serious infections.