Category: Critical Care
Keywords: POCUS, Massive PE (PubMed Search)
Posted: 6/6/2017 by Rory Spiegel, MD
(Updated: 11/27/2024)
Click here to contact Rory Spiegel, MD
The poor sensitivity of bedside echocardiography to identify all-comers with pulmonary embolism is well documented. Most series cite a sensitivity and specificity of 31% to 72% and 87% to 98%, respectively (1,2). But as Nazerian et al demonstrate in their recent publication in Internal and Emergency Medicine, the diagnostic performance of bedside echocardiography is far more reliable in the subset of patients presenting in shock (3).
Of the 105 patients included in the final analysis, in 43 (40.9%) PE was determined to be the etiology of their shock. Bedside echo demonstrated notable diagnostic prowess when employed in this subset of patients, sensitivity (91%), specificity (87%), –LR (0.11), +LR (7.03). The sensitivity and –LR were further augmented when the venous US of the LE was included (sensitivity of 95% and –LR of 0.06) in the diagnostic workup.
1. Dresden S, Mitchell P, Rahimi L, et al. Right ventricular dilatation on bedside echocardiography performed by emergency physicians aids in the diagnosis of pulmonary embolism. Ann Emerg Med. 2014;63(1):16-24.
2. Nazerian P, Vanni S, Volpicelli G, et al. Accuracy of point-of-care multiorgan ultrasonography for the diagnosis of pulmonary embolism. Chest. 2014;145(5):950-957.
3. Nazerian P, Volpicelli G, Gigli C, Lamorte A, Grifoni S, Vanni S. Diagnostic accuracy of focused cardiac and venous ultrasound examinations in patients with shock and suspected pulmonary embolism. Intern Emerg Med. 2017;
Category: Geriatrics
Keywords: Geriatric, cardiology, symptoms, atypical, angina (PubMed Search)
Posted: 6/4/2017 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS
Older patients with acute coronoary syndrome (ACS) are less likely to present with typical ischemic chest pain (pressure-like quality, substernal location, radiating to jaw, neck, left arm/shoulder and exertional component) compared with younger counterparts.
Typical angina symptoms predictive of acute myocardial infarction (AMI) in younger patients were less helpful in predicting AMI in the elderly population.
Autonomic symptoms such as dyspnea, diaphoresis, nausea and vomiting, pre-syncope or syncope are more common accompaniments to chest discomfort in elderly ACS patients.
Symptoms may also be less likely to be induced by physical exertion; instead, they are often precipitated by hemodynamic stressors such as infection or dehydration
Bottom Line: Keep a high index of suspicion for ACS in older patients as they present atypically.
Category: Pharmacology & Therapeutics
Keywords: MSSA, MRSA, bacturia, bacteremia, Staph aureus, Staphlococcus aureus (PubMed Search)
Posted: 6/4/2017 by Jill Logan
(Updated: 11/27/2024)
Click here to contact Jill Logan
Risk factors associated with S. aureus bacturia include:
Al Mohajer M, Darouiche RO. Staphylococcus aureus bacteriura: source, clinical relevance, and management. Curr Infect Dis Rep. 2012;14:601-6.
Category: International EM
Keywords: Tranexamic acid, Post-Partum Hemorrhage (PubMed Search)
Posted: 5/31/2017 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD
Post-partum hemorrhage results in approximately 100,000 deaths annually and is the leading cause of maternal death globally.
In a just published study in the Lancet, among approximately 20,000 women from 21 countries enrolled in the WOMAN study, death due to bleeding was significantly reduced in women given tranexamic acid (1.5%) compared to those in the placebo group (1.9%) {RR 0.81, 95% CI 0.65–1.00; p=0.045)}. This was especially true in women given tranexamic acid with 3 hours of giving birth (1·2%) vs in the placebo group (1·7%) {RR 0.69, 95% CI 0.52–0.91; p=0·008)}.
Bottom line:
The authors’ interpretation “Tranexamic acid reduces death due to bleeding in women with post-partum haemorrhage with no adverse effects. When used as a treatment for postpartum haemorrhage, tranexamic acid should be given as soon as possible after bleeding onset.”
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)30638-4/fulltext
Category: Orthopedics
Keywords: Wrist fracture, splinting (PubMed Search)
Posted: 5/27/2017 by Brian Corwell, MD
Click here to contact Brian Corwell, MD
High energy mechanism in younger patients
Falls more common in older patients
Higher incidence in older women due to osteoporosis
May indicate overall poor bone health
Avoid splinting in positions of flexion (palmer) and ulnar deviation
Palmer flexed positions may have a higher rate of displacement
Extra-articular fx, less than 5mm shortening of radius, Less than 5 degrees of dorsal angulation.
Consider fractures than are only stable in extreme positions to be unstable
If fx involves the ulnar styloid or DRUG (distal radial ulnar joint) place in long area posterior splint with arm in mid supination (anatomic position of forearm)
Category: Toxicology
Keywords: foodborne botulism (PubMed Search)
Posted: 5/25/2017 by Hong Kim, MD
Click here to contact Hong Kim, MD
Botulism is a rare neurologic condition characterized by GI symptoms that progressed to cranial nerve dysfunction and symmetric descending paralysis. Foodborne botulism is due to ingestion of botulinum toxin that is produced by clostridium botulinum, an ubiquitous bacterium in our environment.
Bottom line:
Maryland Department of Health and Mental Hygiene
CDC Emergency Operations Center: 770-488-7100
Foodborne botulism is characterized by
Category: Neurology
Keywords: syncope, vasovagal, orthostatic, blood pressure (PubMed Search)
Posted: 5/24/2017 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS
Vasovagal syncope is a subtype of neurally mediated syncope, and it is distinctly different from orthostatic hypotension.
Patients with orthostatic syncope have severe orthostatic hypotension that results in transient loss of consciousness immediately or within moments of standing up. This is different from neurally mediated syncope, which develops gradually under conditions of prolonged orthostatic stress such as standing for several minutes. Tilt table testing is useful for true orthostatic syncope, but not for neurally mediated syncope. In addition, checking for “orthostatic hypotension” may not capture patient with orthostatic syncope, because the hypotension occurs so quickly after standing up. Of note, patients may still have orthostatic tachycardia or intolerance with neurally mediated syncope.
Category: Critical Care
Posted: 5/23/2017 by Mike Winters, MBA, MD
(Updated: 11/27/2024)
Click here to contact Mike Winters, MBA, MD
Antibiotics in Sepsis
Leisman D, et al. Delayed second-dose antibiotics for patients admitted from the emergency department with sepsis: prevalence, risk factors, and outcomes. Crit Care Med. 2017; 45:956-65.
Category: Orthopedics
Keywords: Reverse Segond Fracture (PubMed Search)
Posted: 5/21/2017 by Michael Bond, MD
(Updated: 11/27/2024)
Click here to contact Michael Bond, MD
It is common teaching that a Segond Fracture is associated with ACL tears. A reverse Segond fracture, avulsion fracture of the knee due to avulsion of the deep fibers of the medial collateral ligament, has also been described that was initially reported as associated with PCL tears. However, a more recent study has not been able to collaborate the PCL connection, but has shown that a reverse Segond fracture is associated with multiple ligamentous injuries to the knee.
Take home point: If you note a Reverse Segond fracture on your plain flips have the patient followup with orthopedics for a possible MRI, as they probably have other ligamentous injuries that might need treatment.
In the study by Peltola et al they looked at 11 years of patients who had CT of their knee and found 10 patiens with a reverse Segond fracture. They found "Reverse Segond fracture is a rare finding even in a level 1 trauma center. Cruciate ligament injuries appear to be associated with avulsion frac- ture, but every patient does not have PCL injury, as previously reported. Our results do not support the association of knee dislocation with reverse Segond fracture."
For a detailed discussion of Segond Fractures please visit Radiopaedia at https://radiopaedia.org/articles/segond-fracture
For Reverse Segond Fractures please visit https://radiopaedia.org/articles/reverse-segond-fracture
Category: Pediatrics
Keywords: Psychiatric, agitation, pediatric (PubMed Search)
Posted: 5/19/2017 by Jenny Guyther, MD
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IM ziprasidone (Geodon) has a relatively quick onset of action with a half-life of 2-5 hours. Although commonly used in adults, there has not been a study looking at an effective dose in pediatrics. Based on the study referenced, the suggested pediatric dose of ziprasidone is 0.2 mg/kg (max 20mg).
This is the first study looking at ziprasidone in the pediatric emergency department population. This was a retrospective observational study of children 5-18 years old who were treated with IM ziprasidone. 40 patients received IM ziprasidone in a tertiary care pediatric emergency department between 2007-2015. 2/3 of the patients had ADHD and 1/3 had autism spectrum disorder. Other diagnosis included post-traumatic stress disorder, bipolar disorder and intellectual disabilities.
68% of patients responded to the initial dose. The initial dose was 0.19 +/- 0.1 mg/kg in the responder group and 0.13 +/- 0.06 mg/kg in the non-responder group. Single doses ranged from 2.5 mg to 20 mg total.
No patients had respiratory depression. Two patients had potential extra-pyramidal symptoms, but one was prior to ziprasidone administration and the other patient had baseline facial twitching with no documentation if there was a change after ziprasidone administration.
Nguyen T, Stanton J and Foster R. Intramuscular Ziprasidone Dosing for Acute Agitation in the Pediatric Emergency Department: An observational Study. Journal of Pharmacy Practice 1-4. 2017.
Category: International EM
Keywords: Meningitis, infectious disease (PubMed Search)
Posted: 5/18/2017 by Jon Mark Hirshon, PhD, MPH, MD
Click here to contact Jon Mark Hirshon, PhD, MPH, MD
Currently, Nigeria is having the worst outbreak of bacterial meningitis in almost 10 years, involving 23 states, 13,420 suspected cases, and 1,069 deaths, as of May 9.
Bacterial meningitis outbreaks frequently occur in West Africa. The area most frequently struck by epidemics of bacterial meningitis is in the sub-Saharan region of Africa. This includes 26 countries and over 400 million people. Epidemics most often occur in the dry season from December-June. Neisseria meningitides serogroup A historically accounts for approximately 90% of the cases.
The U.S. Centers for Disease Control and Prevention recommends quadrivalent vaccines (protects against four serogroups A, C, W, and Y) for individuals traveling or living in countries in which meningococcal disease is hyperendemic or epidemic.
https://www.osac.gov/pages/ContentReports.aspx?cid=3 (Accessed 5/17/2017)
Category: Critical Care
Posted: 5/16/2017 by Kami Windsor, MD
Click here to contact Kami Windsor, MD
High flow nasal cannula (HFNC) is a valid option in the management of acute hypoxic respiratory failure (AHRF) without hypercapnia, as evidenced by multiple studies including the FLORALI trial. Failure of HFNC, however, may result in delayed intubation and worsened clinical outcomes.
Factors predicting HFNC failure and subsequent intubation include:
Consider whether or not HFNC is appropriate in your patient with AHRF, and if you use it, reevaluate your patient to ensure improvement, or escalate their respiratory support.
For patients with acute hypoxic respiratory failure without hypercapnia, the FLORALI trial demonstrated that high flow nasal cannula (HFNC) therapy increases ventilator-free days, reduces 90-day mortality, and is associated with better comfort and lower dyspnea severity when compared to conventional oxygen therapy and non-invasive ventilation (NIV). Failure of HFNC, however, may result in delayed intubation and worse clinical outcomes in patients with acute hypoxic respiratory failure. So how do we predict in the ED which patients are going to fail?
Sztrymf et al. evaluated patients placed on HFNC for nonhypercapneic acute hypoxic respiratory failure, who later went on to require endotracheal intubation. The cohort who failed HFNC had significantly:
- higher RR at 30 & 45 minutes after initiation of HFNC
- lower SpO2% at 15, 30, and 60 minutes
- higher incidence of paradoxical breathing (thoracoabdominal dyssynchrony) at 15, 30, 60, and 120 minutes
In an observational study of patients with ARDS,* Messika et al. found that factors predicting HFNC failure included:
- a higher Simplified Acute Physiology Score II (SAPS II; 46 v. 29, p=.001)
- additional organ system failure (mostly hemodynamic or neurological)
- trends towards lower PaO2:FiO2 ratios and higher RR
So don’t set it and forget it! Consider a different method of respiratory support if your patient has multi-organ system failure, especially if they are in shock or have altered mental status. If you do use HFNC, reevaluate your patient at 15 minutes and again at 30 minutes to make sure their respiratory rate and SpO2 have improved and that there is no paradoxic breathing (or it is resolving). If not, move on to NIV or invasive mechanical ventilation.
*acute respiratory failure occurring within 1 week of known clinical insult with PaO2:FiO2 <300mmHg and bilateral opacities on chest x-ray not attributable to cardiac failure/volume overload
1. Frat JP, Thille AW, Mercat A, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J Med. 2015;372:2185–96.
2. Sztrymf B, Messika J, Bertrand F, et al. Beneficial effects of humidified high flow nasal oxygen in critical care patients: a prospective pilot study. Intensive Care Med. 2011;37:1780–6.
3. Messika J, Ben Ahmed K, Gaudry S, et al. Use of high-flow nasal cannula oxygen therapy in subjects with ARDS: a 1-year observational study. Respir Care. 2015;60(2):162-9.
4. Hernandez G, Roca O, Colinas L. High-flow nasal cannula support therapy: new insights and improving performance. Crit Care. 2017;21(1):62.
Category: Orthopedics
Keywords: Lateral knee pain (PubMed Search)
Posted: 5/13/2017 by Brian Corwell, MD
Click here to contact Brian Corwell, MD
Iliotibial band tendonitis
IT band is the continuation of the tensor fascia lata and inserts on the tibia at Gerdy's tubercle
Common cause of lateral knee pain seen in Primary care/Sports med clinics
Mechanism: May be due to excessive friction between the IT band and the lateral femoral condyle
Second most common overuse injury of the knee (PF syndrome). Not an acute event.
Affects up to15% of active individuals
Impingement zone is at 30 degrees of knee flexion
Most common in runners and cyclists
Pain localized over the lateral femoral condyle. Better w/ rest. Often occurs at a predictable distance into the run and not at onset.
Exacerbated with changes to mileage or running terrain.
Additional risks include poor shoes (best to change every 300 to 500 miles), excessive foot pronation (pes planus), quad versus hamstring strength asymmetry, weak hip ABductors, leg length discrepancy, tight IT band.
Category: Neurology
Keywords: syncope, vasovagal, seizures, orthostatic, blood pressure (PubMed Search)
Posted: 5/10/2017 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS
Cheshire WP. Syncope. Continuum 2017;23(2):335–358.
Category: Orthopedics
Keywords: Lisfranc Fracture (PubMed Search)
Posted: 4/29/2017 by Michael Bond, MD
(Updated: 5/1/2017)
Click here to contact Michael Bond, MD
Lisfranc Fracture: Typically consists of a fracture of the base of the second metatarsal and dislocation, though it can also be associated with fractures of a cuboid.
Click below see image of fracture
Lisfranc Fracture:
Common current mechanism of injury is when a person steps into a hole and twists the foot. The original mechanism of injury that was described was when a horseman would fall of their horse with their foot still trapped in a stirrup.
Diagnosis should be considered if patient has difficultly weight bearing with pain on palpation over the 2nd and 3rdmetatarsals with an appropriate mechanism.
Category: Pediatrics
Keywords: analgesics, Ultram, (PubMed Search)
Posted: 4/28/2017 by Mimi Lu, MD
Click here to contact Mimi Lu, MD
Bottom line: Do not prescribe codeine or tramadol for cough or pain in children and breastfeeding moms.
A summary statement from the American Hospital Association (AHA) is posted below.
FDA RESTRICTS USE OF CODEINE AND TRAMADOL
MEDICINES IN CHILDREN, RECOMMENDS AGAINST USE IN BREASTFEEDING MOTHERS
The Issue:
The Food and Drug Administration (FDA) today announced that it is restricting the use of codeine and tramadol medicines in children, as well as recommending against using codeine and tramadol medicines in breastfeeding mothers due to possible harm to their infants.
Codeine is approved to treat pain and cough, and tramadol is approved to treat pain. These medicines carry serious risks, including slowed or difficult breathing and death, which appear to be a greater risk in children younger than 12 years, and should not be used in these children. These medicines also should be limited in some older children.
The FDA is requiring several changes to the labels of all prescription medicines containing these drugs. These new actions further limit the use of these medicines beyond FDA's 2013 restriction of codeine use in children younger than 18 years to treat pain after surgery to remove the tonsils and/or adenoids. The agency is now adding:
The FDA is urging health care professionals and patients to report side effects involving codeine-and tramadol-containing medicines to the FDA MedWatch program, through its online form.
Category: Toxicology
Keywords: Dextromethorphan, Robotripping (PubMed Search)
Posted: 4/20/2017 by Kathy Prybys, MD
Click here to contact Kathy Prybys, MD
Dextromethorphan Abuse in Adolescence. Bryner JK, Wang K, et al. Archives of Pediatrics & Adolescent Medicine. 2006;160(12):1217-1222. doi:10.1001/archpedi.160.12.1217.
Dextromethorphan abuse. Antoniou T, Juurlink DN. CMAJ?: Canadian Medical Association Journal. 2014;186(16):E631. doi:10.1503/cmaj.131676.
Category: Pharmacology & Therapeutics
Posted: 4/27/2017 by Tu Carol Nguyen, DO
Click here to contact Tu Carol Nguyen, DO
Haloperidol has a higher D2 receptor antagonist effect than standard antiemetic treatment agents such as metoclopramide. In addition, newer antipsychotic agents such as Olanzapine have a high affinity at multiple antiemetic sites such as the dopamine and serotinergic receptors.
While formal RCT's are still in the works, multiple sources including palliative care, emergency medicine, and pain journals support their use in refractory emesis.
Consider Haloperidol 3-5 mg IV.
Check an EKG for long QTc prior to use. Consider dose reduction of haloperidol in those with hepatic impairment. Also consider dose reduction in patients taking carbamazepine, phenytoin, phenobarbital, rifampicin, or quinidine due to that pesky CYP3A4 inhibition.
Consider Olanzapine 2-5 mg IV.
Several case reports have shown a higher rate of success with olanzapine for refractory emesis. Olanzapine has similar precautions as those to haloperidol (EKG, hepatic impairment), although it's CYP drug interactions are less common. Additionally, use olanzapine cautiously in hyperglycemic patients as there are several case reports of olanzapine prompting episodes of DKA. Consider frequent blood sugar checks or small doses of insulin in hyperglycemic patients.
Take Home Points:
Consider the antipsychotic agents Haloperidol or Olanzapine for patients with refractory emesis, they may be more effective than traditional antiemetics.
Get an EKG prior to administration to check for QTc prolongation. As the classical and atypical antipsychotic agents are sedating, use caution in conjunction with other sedating medications (such as benzodiazepines).
Category: Neurology
Keywords: vasogenic cerebral edema, white matter, blood-brain-barrier, steroids (PubMed Search)
Posted: 4/26/2017 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD
Case image courtesy of Dr David Cuete, Radiopaedia.org, rID: 23178
Follow me on Twitter @EM_NCC!
Category: Critical Care
Posted: 4/25/2017 by Mike Winters, MBA, MD
(Updated: 11/27/2024)
Click here to contact Mike Winters, MBA, MD
Ventilator Settings for the Post-Arrest Patient
Jentzer JC, et al. Recent developments in the management of patients resuscitated from cardiac arrest. J Crit Care. 2017; 39:97-107.