Clinical practice in the world of the Electronic Medical Record has made many a clinician question the value of electronic reminders.
Banners warn of sepsis, the need for repeat evaluation, vital signs outside expected limits, wait times, and risks for readmission.
Can they instead help ED flow?
Sayan Dutta and colleagues suggest that they can. When clinicians chose to receive notice of a lab or imaging result, push notification reduced time between final result and ED disposition by 18 minutes (95% CI: 15-21 minutes).
The likely key here? Clinicians actively chose when and about what to be notified.
See: Result Push Notifications Improve Time to Emergency Department Disposition: A Pragmatic Observational Study, Annals of Emergency Medicine, 85(1), 53-62. https://www.annemergmed.com/article/S0196-0644(24)00404-9/abstract.
Crowned dens syndrome is an acute inflammatory disease caused by deposition of calcium pyrophosphate dihydrate crystals or hydroxyapatite crystals in the soft tissue and ligaments surrounding the dense. Patient presentation is severe pain in the neck and base of the skull, low grade fever, and elevated inflammatory markers. It is most commonly seen in elderly females. Ct scan is the gold standard for diagnosis. Once meningitis and other significant infectious process has been excluded, treatment is anti inflammatory medications including steroids.
Infants are typically obligate nasal breathers and the increased mucus production associated with bronchiolitis can impair both breathing and feeding. AAP bronchiolitis guidelines state that the routine use of deep suctioning may not be beneficial.
This was an observational study of 121 infants aged 2-23 months with bronchiolitis who received either nasal suction (31), deep suction (68) or a combination (52). Groups were based on clinician discretion. Respiratory scores and pulse ox were obtained pre-suction and at 30 and 60 minutes post suction.
There was no difference between suction type and respiratory score. However, there was an improvement in respiratory score between the 0-30 and 0-60 time point with any suctioning. Suction type had no effect on pulse ox, airway adjunct escalation, length of stay or outpatient outcomes.
The study also showed no association between albuterol use and respiratory scores (albuterol is not recommended by the AAP in the management of bronchiolitis).
Bottom line: In this small study, nasal aspiration and deep suction appear to be equal in improving respiratory scores up to 1 hour post suction suggesting that deep suctioning may not be needed.
Another large database evaluation of the use of etomidate vs. ketamine as an induction agent for intubation found a trend toward higher mortality in the etomidate group. Even when trying to control for steroid use (to control for etomidate’s possible adrenal suppression), etomidate had a higher mortality rate.
A well done study that adds to the chorus advocating for choosing ketamine when looking for a hemodynamically neutral induction agent.
This was a review of the cardiac arrest registry of Norway between 2016-2021. The incidence of pediatric out of hospital cardiac arrests was 4.6 per 100,000 child years and significantly higher in children < 1 year (20.9 per 100,000 child years). There was an overall 18% one year survival rate in the 308 patients included.
Leading causes of arrests were choking, respiratory disease, drowning and SIDS, making up 67% of cases.
73% of the arrests were initially asystolic and 14% were PEA on EMS arrival. The presence of shockable rhythms increased with age and VT/VF were the initial rhythm in up to 15% of the 13-17 year age group.
88% of patients received bystander CPR ( with 68% receiving both chest compressions and ventilations). A minority of these patients were in a shockable rhythm, but 7 total patients were in refractory VF. Mechanical CPR devices were used in 35 patients aged 11-17. ECMO was started in 19 cases.
Bottom line: The rate of bystander CPR in this study was very high and other jurisdictions can attempt to learn from the system in place in Norway to increase their local prehospital interventions.
High-Intensity NIPPV for Acute COPD Exacerbations?
In adult patients, ultrasound-guided long catheter IVs for difficult venous access have been shown to provide increased duration of use, reduced complication rates, and greater cost-effectiveness.
However, there are relatively few studies examining the use of ultrasound for IV access in pediatric patients.
A recent study, the DIAPEDUS study, investigated the success rate of peripheral IV access with and without ultrasound assistance in pediatric patients with difficult venous access.
The study included 110 pediatric patients. IVs were placed by 25 nurses and 6 pediatricians, each of whom had completed departmental training involving at least 20 ultrasound-guided IV placements prior to the study.
The results showed a significantly higher success rate on the first attempt with ultrasound-guided techniques (90% vs. 18%), along with reduced procedural time and fewer attempts overall.
Bottom Line: For patients with known difficult venous access, ultrasound-guided IV placement should be the first-line approach.
In this randomized trial of restrictive oxygen (arterial oxygen sat of 94% ) vs. liberal oxygen (12-15 L of O2 per minute) for 8 hours after traumatic injury there was no difference in mortality or major respiratory complications at 30 days between the two groups.
Further evidence that managing hypoxia is important but over oxygenation at best offers no benefit and may add harm.
Cardiovascular disease (CVD) is the leading cause of death both in the United States and globally for both men and women.
Major adverse cardiovascular events (MACE) is a commonly used composite outcome.
MACE is defined as non-fatal stroke/acute myocardial infarction/heart failure or cardiovascular death.
Physical inactivity is a leading risk factor for noncommunicable diseases and death worldwide
Up to 5 million deaths/yr could be averted with increased physical activity
Regular physical activity reduces the risk of many types of cancer by 8-28%, diabetes by 17%, heart disease and CVA by 19%, and dementia by 20%.
Many adults and children find meeting the recommended physical activity goals very challenging.
A recent observational study found that just 1.5-to-4-minute small bursts of high intensity exercise throughout the day may help lower an individual’s risk of MACE.
To clarify, this does not mean going to the gym to do a 45-minute HIIT class
Vigorous intermittent lifestyle physical activity (VILPA) involves such simple things as carrying the groceries a short distance or taking the work stairs instead of the elevator.
Such activities are more feasible for all of us vs structured exercise for obvious reasons.
Study group was >100,000 middle-aged men and women. Average age 61.
All participants wore an activity tracker continuously for a full week.
This data was used to calculate VILPA bouts throughout the day.
Female participants with no formal exercise regimen who recorded just 3.4 minutes of VILPA a day were 50% less likely to have a MI, had a 67% decreased risk for heart failure and 45% less likely to develop any type of MACE vs those who did not clock any VILPA during their day.
Female participants who recorded just 1.2-1.6 minutes of VILPA a day had a 33% lower risk of MI, 40% decreased risk of heart failure and 30% lower risk of MACE.
In male participants, those with 5.6 minutes of VILPA each day had a 16% reduced risk of having MACE than those who did not have any VILPA.
Differences may be due to women’s VILPA intensity was roughly 20% greater than men
Conclusion: Take the stairs
Infantile Spasms (now known as Infantile Epileptic Spasms Syndrome- IESS) is a subtle, can't miss diagnosis occurring in children under the age of 2, with 90% presenting before 1 year of age.
History:
Presentation for these patients can be sporadic, recurrent, flexion or extension of the limbs or head. The patient typically remains alert during an episode, but they can be startled or appear uncomfortable from the sudden movement.
With smart phone use, parents often have videos of the events that a provider can see as they are often no events in the ED.
Prognosis is very poor with up to 50% having long-term neuro-cognitive complications or regression.
Examination:
A complete physical exam should be performed with particular attention to focal neurologic deficits which would require emergent imaging, signs of electrolyte abnormalities (eg. Chvostek's sign in hypocalcemia), and evidence of neurocutenous syndromes (eg. Neurofibromatosis, tuberous sclerosis).
Testing:
Diagnosis is made with EEG showing hypsarrhythmia. This should be done as soon as possible, most often requiring an inpatient admission.
Lab work can be done to exclude other possible causes of abnormal movements including assessing for electrolyte abnormalities.
Imaging in the ED is not typically indicated unless there is concern based on exam. MRI is the imaging modality of choice, and is often completed after EEG confirmed diagnosis.
Treatment:
Management is initiated in conjunction with a pediatric neurologist with most common therapies being corticotropin (ACTH) and vigabatrin.
A recent review article highlighted the adverse effects that emergency physicians should know of with the novel antineoplastic agents. The adverse effects and the associated agents are briefly summarized from the article in the table below. A link to the full article is below.
Link to article: Antibody-Drug Conjugates: The Toxicities and Adverse Effects That Emergency Physicians Must Know - Annals of Emergency Medicine
The Venous Excess Ultrasound (VExUS) exam integrates IVC, portal, hepatic, and renal vein findings to assess venous congestion and guide management, such as diuresis, in critically ill patients.
Technique:
Tips:
Interpretation:
Sometimes when other clinical information is contradictory, having the extra data point of the VExUS exam can be extremely useful to determine the best plan for a patient. Practice looking for the portal/hepatic veins and getting the waveforms on patients with a CLEAR clinical picture of venous congestion, then practice on more difficult cases.
This prospective observational study looked at patients with liver lacerations and active contrast extravasation who either had immediate embolization vs. observation. After matching for age, injury score etc. the observation first approach did as well as those who had immediate embolization.
This study tried to expand upon what they describe as the classic triad of signs to diagnose ruptured AAA “(1) abdominal pain, (2) hypotension and (3) a pulsatile abdominal mass”. They tested these against the _modified abdominal aortic aneurysm rupture signs. “_The MARS-signs encompassed (1) the registered pain-associated symptoms or signs, (2) all hypovolemic associated signs, and (3) pulsatile abdominal mass and/or ultrasound finding”. The MARS did slightly better in identifying ruptured AAA retrospectively. For me, this doesn’t add a great deal of help in making this can’t miss diagnosis and further work is necessary.
Background:
Ultrasound-guided subclavian central venous catheter (CVC) placement has become a preferred site due to low risk of infection and a low risk of complication. Complications include arterial puncture, pneumothorax, chylothorax, and malposition of the catheter. Ultrasound guidance can significantly reduce the risk of these complications aside from catheter malposition. The most common sites of malposition are in the ipsilateral internal jugular vein or the contralateral brachiocephalic vein. This study sought to evaluate the rate of catheter malposition between left-and right-sided subclavian vein catheter placement using ultrasound guidance with an infraclavicular approach.
Study:
Results:
Take Home:
For infraclavicular ultrasound-guided subclavian CVC placement, consider using the left-side over the right if no contraindications for left-sided access exist.
Early treatment of congestive heart failure (CHF) exacerbations is associated with improved mortality rates and shorter hospital length of stay. Lung ultrasound is a valuable tool in diagnosing CHF exacerbations. Recently, several studies have explored the use of lung ultrasound in the prehospital settings to expedite diagnosis and treatment.
A recent systematic review and meta-analysis evaluated the diagnostic accuracy and clinical impact of prehospital lung ultrasound. The authors found similar test characteristics to point-of-care ultrasound (POCUS) performed in the emergency department.
The eight studies included in the analysis utilized varying lung ultrasound protocols, analyzing between 2 and 8 lung zones. Notably, only two studies involved paramedics performing the ultrasounds, yet no significant difference in diagnostic accuracy was observed.
Further research is needed to evaluate the training requirements for prehospital providers and the broader impact of prehospital lung ultrasound on treatment strategies and patient outcomes.
Fall from a height of 6 feet with back pain. Plain film shown. What is the diagnosis? Any further imaging indicated? Treatment? Disposition?
As a reminder, prescribing medications to older patients should be done with caution because of changed physiology, co-morbid conditions and other currently used medications. The Beers Criteria is a helpful list of medications that may cause trouble for your older patients. https://www.guidelinecentral.com/guideline/340784/#section-2776198 is a list of medications to either avoid or prescribe carefully in this patient population.
Pay particular attention to medications that have anticholinergic properties as they cause change in mental status and increase the risk for falls.
From all of us at UMEM, Happy Thanksgiving!!
We are incredibly Thankful for each of you and all that you do to care for patients and their families.
We are Thankful for those legends who have blazed the path in EM like Greg Henry who the EM community lost yesterday. Our thoughts are with his family. Thank you Dr. Henry for inspiring so many of us. Our pearls today are two of his famous quotes:
“Medicine is show business for ugly people.”
“You don’t go to Disney and see Mickey taking a smoke break. You have to be on when you are on shift”
