Category: Pediatrics
Keywords: cervical spine, pediatrics, NEXUS (PubMed Search)
Posted: 9/19/2014 by Jenny Guyther, MD
(Updated: 11/27/2024)
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The NEXUS criteria is widely applied to adults who present with neck pain due to trauma. While this study did include about 2000 pediatric patients, there were not enough young children to draw definitive conclusions. For more information on the evaluation of the cervical spine, see Dr. Rice's pearl from 9/7/12. A 2003 study piloted an algorithm for cervical spine clearance in children < 8 years.
Patients were spine immobilized if: unconscious, abnormal neurological exam, history of transient neurological symptoms, significant mechanism of injury, neck pain, focal neck tenderness or inability to assess based on distracting injury (extremity or facial fractures, open wound, thoracic injuries, or abdominal injuries), physical exam findings of neck trauma, unreliable exam due to substance abuse, significant trauma to the head or face, or inconsolable children.
When the 2 pathways (see attached) were implemented, there was a decrease in time to cervical spine clearance. There were no missed injuries in the study period prior to implementation of the pathway or once it was implemented. There was no significant difference in the amount of xrays, CT scans or MRIs.
Lee S, Sena M, Greenholtz, S, Fledderman M. A Multidisciplinary Approach to the Development of a Cervical Spine Clearance Protocol: Process, Rationale, and Initial Results. Journal of Pediatric Surgery 2003; 38 (3): 358-362.
Category: Toxicology
Keywords: ciguatera, scromboid, tetrodotoxin (PubMed Search)
Posted: 9/18/2014 by Hong Kim, MD
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Food poisoning can occur with many different food groups/items, as well as how the food is prepared, handled or stored.
There are three specific “food poisonings” associated with fish consumption can cause serious toxicity/illness beyond GI symptoms: Ciguatera, Scrombroid, tetrodotoxin (puffer fish)
Ciguatera
Symptoms:
May progress to develop…
Treatment: supportive care and mannitol in presence of severe neurologic symptoms (limited evidence).
Scrombroid
Symptoms:
Tx: H1/H2 blockers and supportive care
Serious reactions: treat like allergic/anaphylactic reaction
Tetrodotoxin
Symptoms:
Treatment: supportive care and intubated if needed.
Category: International EM
Keywords: deep venous thrombosis, plane travel, blood clots (PubMed Search)
Posted: 9/16/2014 by Jon Mark Hirshon, PhD, MPH, MD
(Updated: 9/17/2014)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD
While sitting on an international flight, ever wonder what your risks are for a blood clot?
General Background:
It is estimated that the risk for a deep venous thrombosis (DVT) is 3-12% on a long-haul flight. However, the real incidence is difficult to evaluate, due in part to the lack of consensus about 1) diagnostic tests, and 2) the appropriate time frame to relate a venous thromboembolic event (VTE) to travel.
Risks Factors for VTEs on long-haul flights:
Bottom Line:
http://www.cdc.gov/ncbddd/dvt/travel.html
Gavish I, Brenner B. Air travel and the risk of thromboembolism. Intern Emerg Med 2011 Apr;6(2):113-6.
Category: Critical Care
Posted: 9/16/2014 by Mike Winters, MBA, MD
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Infectious Risks Associated with TTM
Kuchena A, et al. Postcardiac arrest temperature management: infectious risks. Curr Opin Crit Care 2014; 20:507-15.
Category: Visual Diagnosis
Posted: 9/15/2014 by Haney Mallemat, MD
(Updated: 10/1/2014)
Click here to contact Haney Mallemat, MD
Football player complains of sudden foot pain after begin tackled. What’s the diagnosis?
Lisfranc fracture-dislocation
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Category: Cardiology
Posted: 9/14/2014 by Semhar Tewelde, MD
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Optimal Revascularization in Complex Coronary Artery Disease
- A multicenter trial 4,566 patients with NSTEMI, unstable angina, and multi-vessel coronary artery disease were enrolled comparing outcomes of cardiac stenting versus coronary artery bypass.
- Cardiac stenting was associated with improved outcomes and lower mortality in the following subgroups: age >65 years, women, unstable angina, TIMI score >4, and 2 vessel disease.
- Despite high clinical risk patients who underwent cardiac stenting compared to surgical revascularization did better in this prospective registry.
Buszman P, Buszman P, Bochenek A, et al. Comparison of Stenting and Surgical Revascularization Strategy in Non-ST Elevation Acute Coronary Syndromes and Complex Coronary Artery Disease (from the Milestone Registry). JACC Oct 2014 Vol 114, Issue 7, pages 979-987.
Category: Orthopedics
Keywords: back pain, x-ray (PubMed Search)
Posted: 9/13/2014 by Brian Corwell, MD
(Updated: 11/27/2024)
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Back pain accounts for more than 2.6 million visits
30% of ED patients receive X-rays as part of their evaluation
Imaging can be avoided in a majority of these patients by focusing on high risk (red flags) findings in the history and physical exam.
Patients who can identify a an acute inciting event without direct trauma likely have a MSK source of pain.
Imaging rarely alters management
Attempt to avoid imaging in patients with nonspecific lower back pain of less than 6 weeks duration, with a normal neurologic exam and without high risk findings (fever, cancer, IVDA, bowel or bladder incontinence, age greater than 70, saddle anesthesia, etc)
Patients with radiculopathy (sciatica) and are otherwise similar to the above also do not require emergent imaging
Category: Pediatrics
Posted: 9/12/2014 by Rose Chasm, MD
(Updated: 11/27/2024)
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Severe Respiratory Illness Associated With Enterovirus D68--Missouri and Illinois, 2014. CDC MMWR. Vol 63. September 2014.
Category: Toxicology
Keywords: digoxin, digoxin-specific antibody fragments, digoxin-Fab (PubMed Search)
Posted: 9/9/2014 by Bryan Hayes, PharmD
(Updated: 9/11/2014)
Click here to contact Bryan Hayes, PharmD
Digoxin-specific antibody fragments (Fab) are safe and indicated in all patients with life-threatening dysrhythmias and an elevated digoxin concentration. However, full neutralizing doses of digoxin-Fab are expensive and may not be required (not to mention cumbersome to calculate).
Based on pharmacokinetic modeling and published data, a new review suggests a simpler, more stream-lined dosing scheme as follows:
In imminent cardiac arrest, it may be justified to give a full neutralizing dose of digoxin-Fab.
In acute poisoning, a bolus of 80 mg (2 vials), repeat if necessary, titrated against clinical effect, is likely to achieve equivalent benefits with much lower total doses.
With chronic poisoning, it may be simplest to give 40 mg (1 vial) at a time and repeat after 60 min if there is no response.
Chan BS, et al. Digoxin-specific antibody fragments in the treatment of digoxin toxicity. Clin Toxicol 2014;52:824-36. [PMID 25089630]
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Category: Neurology
Keywords: blood pressure, stroke (PubMed Search)
Posted: 9/11/2014 by Danya Khoujah, MBBS
Click here to contact Danya Khoujah, MBBS
Why is everyone obsessed about blood pressure management in stroke?
Greater than 60% of patients with stroke have elevated blood pressure, and 15% have a systolic blood pressure (SBP) greater than184 mmHg. That is more common in hemorrhagic stroke than ischemic stroke.
Whether it's an acute hypertensive response or a premorbid uncontrolled hypertension, it is likely to negatively affect the clinical course and neurological outcome.
Below is a suumary of the current guidelines for blood pressure management of stroke subtypes; for a more detailed summary of the guidelines, refer to the original article (below)
Ischemic stroke:
Lytic patients have a target SBP of <185mmHg, whereas nonlytic patients have a higher SBP target of <220mmHg
Hemorrhagic Stroke:
Non-aneurysmal hemorrhage patients with a SBP >180mmHg have a target SBP of <160 mmHg, whereas if their SBP was 150-220 mmHg then lowering it to 140 mmHg is safe. Patients with aneurysmal hemorrhage have a target SBP of <160mmHg
Miller J et al. Management of Hypertension in Stroke. Ann Emerg Med 2014;64:248-255
Category: Critical Care
Posted: 9/8/2014 by John Greenwood, MD
(Updated: 9/9/2014)
Click here to contact John Greenwood, MD
Goal-Directed Resuscitation During Cardiac Arrest
Focusing on high-quality CPR is by far one of the most effective methods to ensure your arrested patient has the best chance to survive. However, emerging evidence suggests that there are additional goals that we should try and accomplish during our resuscitation.
As we continue to move toward goal-directed resuscitation strategies, optimizing coronary perfusion pressure (CPP) may be our next target in “personalizing” the care we provide to those in cardiac arrest.
A recent AHA consensus statement recommended the following physiologic goals during cardiac arrest care:
Each of these variables can give the provider valuable feedback about how their patient is responding to their resuscitation. Some argue that the DBP target should be much higher (>35 mmHg), with the caveat that pharmacologic optimization can only occur once high quality CPR is confirmed. The goal should always be to minimize the use of epinephrine whenever possible!
Bottom Line: During your next cardiac arrest resus, consider using a goal-directed strategy by monitoring the patient’s CPP, DBP, & EtCO2 to determine the effectiveness of your resuscitation.
Suggested Reading
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Category: Visual Diagnosis
Posted: 9/8/2014 by Haney Mallemat, MD
Click here to contact Haney Mallemat, MD
CXR shown below, what's the diagnosis? ...and name 3 differential diagnoses.
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Category: Cardiology
Posted: 9/7/2014 by Semhar Tewelde, MD
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PARADIGM Shift in Heart Failure
- Angiotensin-converting enzymes inhibitors (ACE-I) are cornerstone for treatment of heart failure (HF) given the multiple trials which have shown their positive risk reduction in cardiovascular death.
- Studies looking at the effect of angiotensin-receptor blockers (ARBs) on mortality have been inconsistent; thus ARB's have been recommended as 2nd-line for those who have unacceptable side effects to ACE-I.
- A recent double-blinded RCT (PARADIGM-HF) ~8400 patients with class II-IV HF w/ ejection fraction <40% were treated with enalapril (standard therapy) versus novel therapy with neprilysin (neutral endopeptidase) inhibitor combined with an ARB.
- Primary outcomes were death from cardiovascular causes and hospitalization for HF; The RCT was ceased early (~27 months) because of an overwhelming benefit with the new agent.
- At study closure death occurred 26.5% in the standard group versus 21.8% in the novel group. The risk of HF hospitalization was decreased 21% with novel therapy.
- In early studies the use of a neprilysin inhibitor combined with an ARB has shown superior effects to current standard therapy (ACE-I), however long-term effects of this novel therapy are yet to be determined.
McMurray J, Packer M, Desai A, et al. Angiotension-Neprilysin Inhibition versus Enalapril in Heart Failure. NEJM August 30, 2014.
Category: Pharmacology & Therapeutics
Keywords: HIV, Pre-Exposure Prophylaxis, PrEP (PubMed Search)
Posted: 8/30/2014 by Bryan Hayes, PharmD
(Updated: 9/6/2014)
Click here to contact Bryan Hayes, PharmD
In May 2014, the U.S. Public Health Service released the first comprehensive clinical practice guidelines for PrEP.
Pre-Exposure Prophylaxis (PrEP) has been shown to decrease the risk of HIV infection in people who are at high risk by up to 92%, if taken consistently.
How this applies to the ED patient:
For more information, the CDC has a comprehensive website dedicated to PrEP.
Centers for Disease Control and Prevention. (2014). Pre-Exposure Prophylaxis (PrEP). Retrieved from http://www.cdc.gov/hiv/prevention/research/prep/.
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Category: Toxicology
Keywords: Halogenated hydrocarbons, cardiac sensitization (PubMed Search)
Posted: 9/4/2014 by Kishan Kapadia, DO
(Updated: 11/27/2024)
Click here to contact Kishan Kapadia, DO
Dysrhythmia-induced sudden death, termed "sudden sniffing death syndrome," is well described phenomena due to inhalant (chlorinated and aromatic hydrocarbon) abuse.
Common inhalants include:
Chlorinated hydrocarbons: Degreasers, spot removers, dry-cleaning agents
Fluorocarbons: Freon gas, deodarants
Toluene: Paint thinners, spray paint, airplane glue
Butane: Lighter fluid, fuel
Acetone: Nail polish remover
The common theory behind the syndrome is cardiac sensitization that increases susceptibility of the heart to systemic catecholamines (epinephrine, norepinephrine, etc). Usually, it occurs after an episode of exertion in that any excess catecholamine exposure causes irritability of the myocardium, resulting in dysrhythmias (V. fib, V. tach) and cardiac arrest.
If acute dysrhythmias is due to myocardial sensitization, sympathomimectis should be avoided. Beta-adrenergic antagonist can be used for the catecholamine-sensitized heart.
Category: International EM
Keywords: Hyperthermia, heat stroke, environmental (PubMed Search)
Posted: 9/1/2014 by Jon Mark Hirshon, PhD, MPH, MD
(Updated: 9/3/2014)
Click here to contact Jon Mark Hirshon, PhD, MPH, MD
Hyperthermia can be defined as a core body temperature > 38.5ºC. In contrast to fever, the body’s temperature rises uncontrollably and the body is not able to dissipate the heat. There can be many causes of hyperthermia, including from environmental exposure.
There are two main environmental heat illnesses, heat exhaustion and heat stroke.
Heat exhaustion:
Heat stroke
Bottom line:
Management of the hyperthermic patient. Calvello EJ, Hu K, Khoujah D. Br J Hosp Med (Lond). 2011 Oct;72(10):571-5
Cooling Techniques for Hyperthermia by Schraga ED, Kates LW. Available at: http://emedicine.medscape.com/article/149546-overview
Category: Critical Care
Posted: 9/2/2014 by Haney Mallemat, MD
(Updated: 10/1/2014)
Click here to contact Haney Mallemat, MD
Vasopressors are used in shock-states to increase mean arterial pressure (MAP) and improve distal tissue perfusion. Additionally, some agents have effects on the heart to augment cardiac output.
Receptors that vasopressors work on include:
Norepinephrine (NE): excellent vasopressor for most types of shock and recommended as a first-line agent in the Surviving Sepsis Guidelines.
Epinephrine (a.k.a. Adrenaline): in several countries the first-line agent for shock (including sepsis).
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Category: Visual Diagnosis
Posted: 9/1/2014 by Haney Mallemat, MD
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You are scaning the liver with ultrasound and you see this. What's the diagnosis?
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Category: Cardiology
Keywords: Sick Sinus Syndrome (PubMed Search)
Posted: 8/31/2014 by Semhar Tewelde, MD
Click here to contact Semhar Tewelde, MD
Sick Sinus Syndrome
- Sick sinus syndrome (SSS) is a cardiac conduction disorder characterized by symptomatic dysfunction of the sinoatrial (SA) node.
- SSS usually manifests as sinus bradycardia, sinus arrest, or sinoatrial block, and is sometimes accompanied by supraventricular tachydysrhythmias.
- Symptoms of SSS include: syncope, dizziness, palpitations, exertional dyspnea, fatigability from chronotropic incompetence, heart failure, and angina.
- Clinically significant SSS typically requires pacemaker implantation. Approximately 30% to 50% of pacemaker implantation in the United States list SSS as the primary indication.
- 2 large, prospective cohorts with an average follow-up of 17 years, observed the incidence of SSS increases with age, does not differ between men and women, and is lower among blacks than whites.
- Risk factors for SSS included greater BMI & height, elevated NT-proBNP level & cystatin C level, longer QRS interval, lower heart rate, hypertension, and right bundle branch block.
Jensen P, Gronroos N, et al. Incidence of and Risk Factors for Sick Sinus Syndrome in the General Population. Journal of the American College of Cardiology. Vol 64 Issue 6, pages 531-538
Category: Orthopedics
Keywords: radiology, ankle, fracture (PubMed Search)
Posted: 8/30/2014 by Michael Bond, MD
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Some radiology pearls concerning ankle pain and fractures courtesy of David Bostick and Michael Abraham
Maisonneuve fracture – fracture of the medial malleolus with disruption of the tibiofibular syndesmosis with associated fracture of the proximal fibular shaft (http://radiopaedia.org/articles/maisonneuve-fracture)
When to look for high fibular fracture
Always look for avulsion fracture of 5th metatarsal styloid in patients with ankle pain and
no obvious fractures
Dans-Weber Classification – for lateral malleolar fractures (http://radiopaedia.org/articles/ankle-fracture-classification-weber)