UMEM Educational Pearls

The Critically Ill Geriatric Patient with Sepsis

  • Due to the age-related physiologic change of immunosenescence, geriatric patients have an increased susceptibility to infection, a decreased ability to mount a response to infection, and an increased likelihood of atypical presentations.
  • Atypical presentations of sepsis in the geriatric patient include confusion, decreased functional status, generalized weakness, and failure to thrive.
  • In fact, up to 33% of geriatric patients with bacteremia will be afebrile upon presentation.
  • Consider sepsis in the differential diagnosis of geriatric patients with these nonspecific complaints.

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Category: Orthopedics

Title: Synthetic turf playing fields

Keywords: Playing surface, concussion (PubMed Search)

Posted: 10/12/2019 by Brian Corwell, MD
Click here to contact Brian Corwell, MD

Synthetic turf playing surfaces have been growing in popularity over the last decade and seem to have become a new standard.

Due to the need for durable fields that can accommodate multiple teams/activities, in addition to the high cost of maintaining grass and the need to conserve water, many parks and schools have switched from grass to turf. Turf is advertised as maintenance free but ….this is not the case.

Locally, at M&T Bank Stadium, groundskeepers drive a LitterKat turf sweeper across the field for 4 hours 2-3 times a week to ensure that the synthetic rubber is cleaned and distributed evenly. The field is also repainted every 4 games because the paint may become hard. The cost of this level of maintenance is beyond what many parks and local high schools can afford.

A recent study examined high school concussion data at almost 2000 high schools with over 14,000 recorded concussions. Researchers concluded that more concussions occurred in games than practices. Interestingly, they also found that playing surface was significantly associated with concussion. Almost 90% of all injuries occurred on turf-based surfaces. Turf outweighed all other mechanisms of injury, including helmet-to-helmet hits and grass playing surface. Between 10 and 15.5% of concussions occur from helmet to ground contact. In the NFL, this mechanism accounts for about 1 in 7 concussions.

 

Attempting to limit total exposure time in practice and games on turf surfaces may be beneficial until more study is needed.

 

 


Category: Toxicology

Title: Trend of suicide attempt in adolescent and young adults

Keywords: suicide attempt, adolescent, young adults, epidemiological trend (PubMed Search)

Posted: 10/10/2019 by Hong Kim, MD, MPH (Updated: 10/18/2019)
Click here to contact Hong Kim, MD, MPH

 

The rate of suicide attempt has been increasing over the past decade. A recently published article investigated the temporal trend of suicide attempts in adolescent/young adult population (10 – 25 years old) from 2000 to 2018.

 Methods

  • All intentional – suspected suicide cases were identified from the National Poison Data System from Jan 1, 2000 to December 31, 2018. 
  • Following age groups were compared: 10-12, 13-15, 16-18, 19-21 and 22-25 years old.

Results

  • A total of 1,677,435 cases were identified with 0.1% fatality (n=1579).
  • Female: 70.6% (n=1,184,691) 
  • Single substance (64.1%; n=1,074,423)
  • Highest suicide attempt rate: 16-18 years (30.1%; n=504,682)
  • Lowest suicide attempt rate: 10-12 years (2.3%; n=38,428)
  • The suicide attempt rate increased significantly starting 2011 in 10-12, 13-15 and 16-19 years age groups with seasonal trend
    •  Higher during school months (Sept to May) vs. non-school months (June-August)

Top 5 substance involved in suicide attempt

  1. OTC analgesics
  2. Antidepressants
  3. Sedative hypnotics
  4. Antihistamines
  5. Antipsychotics

Agents associated with serious medical outcome (after 2011)

  1. Antidepressants
  2. OTC analgesics
  3. Antihistamines 
  4. ADHD medications
  • ADHD medicaitons: common in 10-15 years population
  • Sedative hypnotics (e.g. benzodiazepines): common in older age group (16-25 years)

Conclusion

  • Rate of suicide attempt in adolescent and young adults has increase, especially since 2011.
  • The substance used in suicide attempt usually involves medications available to the specific age group.
  • OTC medications (analgesics and antihistamines) were involved in a third of the suicide attemps.

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Rationale: Data regarding temperature management in patients suffered from cardiac arrest with nonshockable rhythm was inconclusive.

Objective: whether moderate hypothermia at 33C, compared with normothermia at 37C would improve neurologic outcome in patients with coma after cardiac arrest with nonshockable rhythm.

Outcome: survival with favorable 90-day neurologic outcome (Cerebral Performance Category scale 1-2/5)

SummaryThere was higher percentage of patients achieving CPC 1-2 in the hypothermia group (10.2%) vs normothermia group (5.7%, Hazard Ratio 4.5, 95% CI 0.1-8.9, p=0.04)

This randomized multicenter trial involved 581 patients with cardiac arrest and nonshockable rhythm.  Hypothermia group included 284 patients vs. 297 in the normothermia group.  Median GCS at enrollment = 3.

Majority of patients was cooled with the use of a basic external cooling device: 37% for hypothermia and 50.8% for normothermia group.

There was higher percentage of patients achieving CPC 1-2 in the hypothermia group (10.2%) vs normothermia group (5.7%, Hazard Ratio 4.5, 95% CI 0.1-8.9, p=0.04)

Limitation:

A. The study used strict enrollment criteria:

  1. CPR initiation within 10 minutes;
  2. CPR to ROSC within 60 minutes;
  3. epinephrine or norepinephrine infusion at < 1 ug/kg/min;
  4. No Child-Pugh class C liver cirrhosis

B. normothermia group had higher proportion of patients with temperature at 38C.

C. Hypothermia group underwent temperature management of 56 hours vs. 48 hours for normothermia patients.

Take home points:

In a selected group of patients with cardiac arrest and nonshockable rhythm, moderate hypothermia at 33C may improve neurologic outcome.

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Category: Toxicology

Title: Clinical and demographic characteristics of e-cigarrette exposure: 2010-2018

Keywords: e-cigarrette liquid exposure, National Poison Data System (PubMed Search)

Posted: 10/3/2019 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

 

E-cigarette (vaping) use has become increasingly popular over the past 10 years, especially among adolescents. Intentional exposure (i.e. ingestion in self harm) of nicotine (e-cigarette liquid) can be life threatening where it can produce mixture of stimulatory (early), cholinergic toxicity and muscle paralysis/respiratory failure by blocking the neuromuscular junction. However, the severity of clinical toxicity in unintentional exposure can vary widely depending on the dose/route/circumstance of their exposure.

A recently published study investigated the characteristics of e-cigarette liquid exposure between Jan 1, 2010 to Dec 31, 2018 using the National Poison Data System

Result

  • Total reported exposure: 17,358.
  • e-cigarette exposure report increased starting 2013 (n=1435), peaking in 2014 (3742). 2018 (n=2901).

Top 4 clinical/demographic characteristics are listed below.

Age group:

  • < 5 years: 64.8%
  • 25+ years: 15.4%
  • 18-24 years: 8.3%
  • 12-17 year: 3.4%

Route of exposure

  • Ingestion: 77.5%
  • Dermal: 13.0%
  • Inhalation/nasal: 10.4%
  • Ocular: 7.1% 

Level of care:

  • Not referred to health care facility (HCF): 60.9%
  • Treated and released from HCF: 27.4%
  • Admitted: non-critical care: 0.8%, critical care: 0.6%

Clinical effects - overall

  • Vomiting: 25.4%
  • Nausea: 11.8%
  • Ocular irritation: 11.3%
  • Dizziness/vertigo: 5.1%

In <5 years group

  • Vomiting: 47.1%
  • Cough/choking: 10.2%
  • Drowsiness/lethargy: 5.7%
  • Nausea: 5.5%

Conclusion

  • e-cigarette exposure predominantly occurs in young children (< 5 y/o)
  • Clinical toxicity are usually self-limited and often not referred to HCF.
  • Severe toxicity is possible, although infrequent, from unintentional exposure.

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Blood Transfusion Thresholds in Specific Populations

Sepsis - 7 g/dL

  • non-inferior to 9 g/dL (which was previously recommended in early goal-directed therapy and early Surviving Sepsis guidelines)

Acute Coronary Syndrome - no current specific recommendations pending further studies

  • recent MINT pilot study showed unexpected trend toward higher combined mortality and major cardiac events in restrictive transfusion arm (8 g/dL) vs. liberal arm (10 g/dL)

Stable Cardiovascular Disease - 8 g/dL

  • no difference in 30-day mortality compared to 10 g/dL, excluding those who have undergone cardiac surgery

Gastrointestinal Bleeds

  • UGIB - 7 g/dL (unless intravascularly volume depleted or h/o CAD)
    • better 6 week-survival, less re-bleeding compared to 9 g/dL
  • LGIB - 7 g/dL, limited evidence, but based on UGIB data

Acute Neurologic Injury - Traumatic Brain Injury - 7 g/dL

  •  no significant difference in neurologic recovery at 6 weeks or mortality vs. 10 g/dL, although there were more brain tissue hypoxia events in restrictive arm
  •  anemia and transfusions both associated with worse outcomes in TBI

Postpartum Hemorrhage - 1:1:1 ratio strategy

  • FFP/RBC ratio ≥  1 associated with improved patient outcomes

Show References


Category: Orthopedics

Title: Intersection Syndrome

Keywords: Tenosynovitis, wrist pain (PubMed Search)

Posted: 9/28/2019 by Brian Corwell, MD (Updated: 10/18/2019)
Click here to contact Brian Corwell, MD

Intersection Syndrome

 

De Quervain’s is a common tenosynovitis is involving the  the 1st dorsal compartment of the wrist/forearm.

Intersection syndrome is a tenosynovitis that occurs at the intersection of the 1st and 2nd dorsal compartments.

Pathology located at crossing point of the 1st compartment structures (APL and EBP) with the radial wrist extensors (ECRB and ECRL)

Occurs most commonly from repetitive wrist extension and is common in rowers, weight lifters, and in those playing racquet sports.

Occurs about 4 to 6cm proximal to the radiocarpal joint VERSUS De Quervain’s which occurs near the level of the radial styloid.

Pain worse with resisted wrist and thumb extension

Radiographs not required

Splint and start NSAIDs

Recalcitrant cases can be referred for corticosteroid injection

 

https://stemcelldoc.files.wordpress.com/2012/09/intersection-syndrome-referral-pain-pattern1.jpg

 

 

 

 

 

 

 


Category: Neurology

Title: Acute Nontraumatic Headache: CT/LP or Not?

Keywords: ACEP, SAH, imaging, nonopioid, CTA, LP (PubMed Search)

Posted: 9/25/2019 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

  • The ACEP clinical policy on the evaluation and management of acute nontraumatic headache in the ED was recently updated.
  • Similar to prior policies, it focuses on the diagnosis of subarachnoid hemorrhage (SAH) due to the disproportionate amount of literature in comparison to other high risk etiologies.
  • In summary:

    1. Are there risk-stratification strategies that reliably identify the need for emergent neuroimaging?
      • The Ottawa SAH Rule has a high sensitivity but low specificity for patients presenting with a normal neurological exam and peak headache intensity within 1 hour of symptom onset (Level B recommendation).
      • Caution in application of this rule, as use in the incorrect population may increase unnecessary testing.
    2. Are nonopioids preferred to opioids for treatment of acute primary headache?
      • Preferentially use nonopioid medications in the treatment of acute primary headaches in ED patients (Level A recommendation).
      • Consider discharge medication and education to reduce headache recurrence and repeat ED visit.
    3. Does a normal noncontrast head CT performed within 6 hours of headache onset preclude the need for further diagnostic workup for SAH?
      • Noncontrast head CT using at least a 3rd generation scanner performed within 6 hours of headache onset can be used to rule out nontraumatic SAH (Level B recommendation).
      • If clinical suspicion remains high despite the negative noncontrast head CT, further evaluation may be pursued.
    4. In a patient who is still considered to be at risk for SAH after a negative noncontrast head CT, is CTA as effective as LP to rule out SAH?
      • Use shared decision making to select the best modality for each patient after weighing the potential for false-positive CTA and the pros/cons associated with LP (Level C recommendation).
  • This clinical policy does not address the evaluation of other potential etiologies for acute headache, including in the pregnant woman and postpartum woman. 

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Category: Critical Care

Title: Vaping Associated Pulmonary Illness (VAPI)

Keywords: VAPI, acute respiratory failure, vaping, e-cigarettes, e-hookah, juul, pulmonary disease, acute lung diease, ARDS (PubMed Search)

Posted: 9/23/2019 by Kami Windsor, MD (Emailed: 9/24/2019)
Click here to contact Kami Windsor, MD

Takeaways

 

The U.S. is currently experiencing an epidemic of a severe lung disease termed Vaping-Associated Pulmonary Illness (VAPI), with over 500 cases and 7 deaths across 38 states and 1 U.S. territory since July 2019.

The clinical presentation of VAPI varies -- 

  • Respiratory (SOB, cough, chest pain), constitutional (fever, tachycardia, headache, dizziness), and potentially GI symptoms (vomiting, diarrhea) after the use of vaping devices. GI symptoms may precede respiratory issues.
  • Can take days or worsen over weeks and can present or end up with severe respiratory failure

Diagnostics --

  • Labs nonspecific: Leukocytosis, elevated ESR, no specific infectious etiology
  • Chest CT generally with bilateral infiltrates
  • Bronchoscopy with BAL demonstrates PMNs and may have lipid-laden macrophages on Oil red O or Sudan staining

Treatment is supportive +/- steroids -- 

  • Current recommendations to treat similarly to ARDS in intubated patients
  • Potential benefit to steroids if not contraindicated

 

Bottom Line: Include vaping-associated pulmonary illness in your differential for patients presenting with acute lung disease.

  • Ask patients about use of e-cigarette/vaping devices.
  • Notify the CDC or your state health department of any suspected cases.
  • Counsel your patients to avoid the use of these devices, at the very least until the specific causative agent is found.

 

Image result for vapi map vaping associated pulmonary illness

 

Show More In-Depth Information

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Category: Pediatrics

Title: Pediatric Tibial tubercle avulsion fractures

Keywords: Orthopedics, compartment syndrome (PubMed Search)

Posted: 9/20/2019 by Jenny Guyther, MD (Updated: 10/18/2019)
Click here to contact Jenny Guyther, MD

-       Tibial tubercle avulsion fractures are rare and pediatrics, accounting for less than 3% of all epiphyseal injuries in children ages 11-17 years. 

-       The typical mechanism is a sudden forceful quadriceps contraction.  Patients present with sudden pain after sprinting or jumping with pain, bruising, deformity or swelling over the tibial tubercle and with a decrease ability to extend the leg. 

-       10 to 20% of cases result in anterior compartment syndrome related to the rupture of the anterior tibial recurrent artery.

-       Although directly measured intra-compartmental pressures can facilitate the diagnosis of compartment syndrome, interpretation of these values can be challenging with healthy children having higher average lower leg compartment pressures than adults.  Treatment of subsequent compartment syndrome is often based on a high index of suspicion.

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Category: Toxicology

Title: Capsaicin for cannabinoid hypermesis syndrome?

Keywords: capsaicin, cannabinoid hyperemesis syndrome, marijuna use. (PubMed Search)

Posted: 9/19/2019 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

 

Cannabinoid hyperemesis syndrome [CHS] (i.e. cyclic/recurrent nausea, vomiting and abdominal pain) is associated with long-term and frequent use of marijuana. Patients with CHS often report temporary relief of symptoms with hot water/shower exposure. Emergency room providers may encounter a growing number of patients with CHS with increasing legalization of marijuana-containing products.

Topical capsaicin has been gaining interest as a potential adjunct to the conventional management of patients with CHS (e.g. antiemetics, opioids, benzodiazepines and antipsychotics).

A small retrospective study was performed involving 43 patients who had multiple visits, and were treated with and without capsaicin. The primary outcome was the ED length of stay (LOS).

Results

  • Most frequently administered medications in both groups were:
  1. Anti-emetics
  2. Haloperidol
  3. Diphenhydramine 
  • Median ED LOS: no significant difference
    • Capsaicin vs. non-capsaicin: 179 min (IQR: 147, 270) vs. 201 min (IQR: 168, 310) (p=0.33)
  • Capsaicin group showed
    • Decreased opioid used: 69 mg vs. 166.5 mg oral morphine equivalents
    • Fewer additional medication administration: 3 vs. 4 doses (p=0.015)
    • Shorter median time to discharge after last medication administration: 60 min (IQR: 35, 115) vs. 92 min (IQR: 47, 155) (p=NS) 
  • 67% of the visit where capsaicin was used required no additional medication.

 

Conclusion

  • Capsaicin use did not decrease ED LOS.
  • However, there was a decrease in total medications administered and opioid requirement.

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Most non-OB physicians experience some fear or anxiety over taking care of the average pregnant patient. There are two patients to consider when caring for these women. Critical illness adds another layer of complexity to an already challenging patient population. Due to the normal physiologic changes that occur during pregnancy there are specific and important factors to be aware of when considering and preparing for intubation.

  • Difficult intubations occur up to 5% of pregnant women.
  • Edema occurs in the OP regions resulting in a narrowed OP diameter, especially with advancing gestational age. A smaller than anticipated ET tube might be necessary.
  • Weight gain and/or obesity make visualization difficult Consider the ramp position to bring the external auditory meatus and the sternal notch into a horizontal line.
  • Aortocaval compression decreases blood return to the heart and can result in hypotension on induction. Consider the use of a wedge under the patient’s right hip to decrease compression during intubation, especially those in later stages of pregnancy.
  • Risk of aspiration is increased due to decreased lower esophageal sphincter tone. Consider administering metoclopramide prior to intubation which selectively increases esophageal sphincter.
  • Functional residual volume in addition to increased oxygen consumption and metabolic demand lead to quicker desaturations and a greater intolerance to hypoxia and apnea. 
  • Be prepared with back up or adjunctive airway options including a video laryngoscope (like Glidescope), an LMA or a supraglottic airway. Although the LMA and supraglottic airways are rescue options in the setting of failed ET intubation, they can often adequately oxygenate and ventilate while urgently consulting with anesthesia colleagues in order to obtain a definitive airway.
 

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Category: Orthopedics

Title: Imaging of Lisfranc Injuries

Keywords: foot fracture, radiology (PubMed Search)

Posted: 9/14/2019 by Brian Corwell, MD (Updated: 10/18/2019)
Click here to contact Brian Corwell, MD

Imaging of Lisfranc Injuries

Tarsometatarsal fracture-dislocation

Anatomy

         3 Columns of the midfoot, divided by the tarsometatarsal joints

  1. Medial
    1. First TMT joint
  2. Middle
    1. 2nd and 3rd TMT joints
  3. Lateral
    1. 4th and 5th TMT joints

The Lisfranc ligament

     - Extends from the 2nd MT to the medial cuneiform

     - Critical to structure and stabilization of the 2nd MT and the midfoot arch

 

Imaging 

Plain films: AP/lateral/oblique

Consider weight bearing view with contralateral comparison if high suspicion

CT: Can be useful to confirm abnormal plain films

MRI: not done in ED but can be used to diagnose pure ligament injuries

Below is a review of the lines of the foot which will ensure not missing this diagnosis. May be helpful to review with sample imaging.

Plain films findings: https://prod-images.static.radiopaedia.org/images/49189279/86408d5bae08ab80ae9ef377337ab7_big_gallery.jpeg

 

On AP view:

  1. Discontinuity of a line drawn from the medial part of 2nd MT to the medial side of the 2nd cuneiform
  2. Widening of the interval between the 1st and 2nd ray
  3. Bony fragment in 1st MT space (fleck sign) – Lisfranc ligament avulsion

On Lateral view:

  1. Dorsal displacement of the proximal 1st or 2nd MT (may be subtle)

On the Oblique view:

  1. Discontinuity of a line drawn from the medial border of the 3rd cuneiform with the medial border of the 3rd MT
  2. Discontinuity of a line drawn from the medial side of the 4th MT with the medial side of the cuboid 

Remember that the lateral margin of the 5th MT can project lateral to the cuboid (up to 3 mm)

 

Lines drawn on 2 view foot for review

https://radiopaedia.org/cases/lisfranc-ligament-normal-alignment

 

 

 

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Category: Pediatrics

Title: UTI Calculator

Keywords: UTIcalc, SBI, serious bacterial infection, febrile infant, urinary tract infection (PubMed Search)

Posted: 9/13/2019 by Mimi Lu, MD
Click here to contact Mimi Lu, MD

Question:  In febrile children younger than 2 years, what combination of clinical and laboratory variables best predicts the probability of a urinary tract infection?

Given that urinary tract infections (UTI) are the most common source of serious or invasive bacterial infections in young febrile infants, early identification and treatment has the potential to reduce poor outcomes.  Wouldn't it be great if there was an easy way to identify patients at highest risk?

Researchers from the Children’s Hospital of Pittsburgh formulated a calculator (UTICalc) that first estimates the probability of urinary tract infection (UTI) based on clinical variables and then updates that probability based on laboratory results.

  • The nested case-control study of 2,070 children aged 2 to 23 months with a documented temperature of 38°C or higher
  • In contrast with the American Academy of Pediatrics algorithm, the clinical model in UTICalc reduced testing by 8.1% (95% CI, 4.2%-12.0%) AND decreased the number of missed UTIs.

Bottom line:

The UTICalc calculator can be used to guide to tailor testing and treatment in children with suspected urinary tract infection with the hope of improving outcomes for children with UTI by reducing the number of treatment delays.

Go ahead and give it a click!! https://uticalc.pitt.edu/

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Category: Toxicology

Title: Officer, I'm not drunk. I just used a mouth wash!

Keywords: ethanol, breath analyzer, mouth wash (PubMed Search)

Posted: 9/12/2019 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

 

Breath analyzers are commonly used by law enforcment officers to test for alcohol intoxication. Breath analyzer uses ethanol partition ratio between blood:breath of 1:2100 = 1 gm of ethanol in 2100 mL of breath/air.

Mouth wash products are frequently used for oral hygiene, and at times, to "mask" odor of substances. These products are readily available in any grocery stores or pharmacy and contain upto 26.9% ethanol (e.g. Listerine) (18.9% - Scope; 14.0% - Cepacol).  

Recently, a small study using healthy volunteers (n=11) was published to investigate the impact of limited ethanol exposure (mouth wash and ethanol vapor) on the breath-alcohol concentration (BrAC).

 

Method

  1. Ethanol vapor exposure (856 mg/m3) for 15 minute. 
  2. Oral rinse (for 30 sec) using mouth wash containing 22% ethanol, 1 hour after the ethanol vapor exposure
  3. Blood and breath samples were collected before, between and after exposure.

 

Results

Blood: No or very low levels of ethanol (0.002 mg/g) were detected in blood at all collection time for both exposures.

BrAC - first collection -- seconds after exposure

  • Ethanol vapor: 0.14 mg/L (0.014 mg/dL)
  • Mouth wash: 4.4 mg/L (0.44 mg/dL)

 

Mean time to negative BrAC level (Swedish statutory limit of 0.1 mg/L = 0.01 mg/dL in air) (FYI: US limit = 80 mg/dL)

  • Ethanol vapor: 0.5 min (0.06 - 0.7 min)
  • Mouth wash: 11 min (6 - 15 min) 

 

Conclusion

  • Ethanol vapor did not affect the BrAC
  • Mouth wash use can transiently increase BrAC; however, their use does not sufficiently increase the BrAC to result in "false positive" based upon US limit.

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Category: Critical Care

Title: VAD Troubleshooting

Keywords: VAD, LVAD, Heart Failure (PubMed Search)

Posted: 9/9/2019 by Mark Sutherland (Emailed: 9/10/2019) (Updated: 9/10/2019)
Click here to contact Mark Sutherland

It's important to remember the differential for the patient with Ventricular Assist Device (VAD) difficulties, as these patients are likely to show up in your ED. 

 

1) Assess the patient as you usually would (signs of life, mental status, breathing, arrhythmias on monitor, etc). Listen for a hum over the chest.  Don't expect to feel a pulse.

2) Look at the VAD including controller, driveline, and power source for alarms, disconnections, signs of infection, and other obvious issues.

3) Look at the power (displayed flow), pulsatility index, and pump speed on the controller to help determine the cause of the issue (see attached chart).  Once you have a suspected etiology, typical management of these issues is usually similar to non-VAD patients (i.e. gentle IVF for hypovolemia, vasodilators if low flow is due to afterload/hypertension, defibrillation/CPR for arresting pts, etc).

Don't forget to call your VAD coordinator when able.  Consider a-line placement for precise evaluation of blood pressure (focus on MAP).

 

Bottom Line: Consider obstruction/thrombosis, bleeding, infection, hypovolemia, afterload/hypertension, arrhythmia, worsening LV function, and suction events when troubleshooting VADs.  The power, pulsatility index, and pump speed help differentiate these conditions.

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Attachments

VAD_Differential.jpg (134 Kb)


Category: Pharmacology & Therapeutics

Title: The Return of Droperidol

Keywords: droperidol (PubMed Search)

Posted: 9/7/2019 by Ashley Martinelli (Updated: 10/18/2019)
Click here to contact Ashley Martinelli

Droperidol is a butyrophenone with primary action as a dopamine D2 receptor antagonist.  Historically, it has been used to treat a variety of conditions from nausea and headaches to acute agitation.  In 2001, the FDA issued a black box warning for risk of cardiac arrhythmias. Following this warning, droperidol was on national shortage for several years, further limiting its use.

Several months ago, droperidol returned to the US market and is available at some institutions. Below is a refresher on dosing and monitoring.  Similar to haloperidol, droperidol can cause extrapyramidal symptoms. Consider pre-treatment with diphenhydramine.

Dosing Recommendations:

Nausea and vomitting: 1.25 mg IV

Headache: 2.5 mg IV, 5 mg IM

Acute agitation: 5mg IM/IV

QTc prolongation is still a concern, especially at higher doses. If using doses > 2.5mg, or using repeated doses, obtain an ECG to ensure safe use of this medication. If the QTc is greater than 440 msec for males or 450 msec for females, droperidol is not recommended.  There is little data regarding the risk with lower doses. Utilize clinical judgement and assess patient risk factors.

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Numerous different household products can potentially be misused/abused. One such product is whipped cream charger/propellant that contains nitrous oxide.

Acute toxicity produce dose dependent response

  • Euphoria 
  • Anxiolysis
  • Sedation
  • Unconsciousness
  • Asphyxiation

Chronic toxicity causes myeloneuropathy (demyelination of the dorsal and lateral columns of the spinal cord) due to vitamin B12 deficiency

  • Extremity paresthesias
  • Ataxia
  • Peripheral sensory neuropathy (loss of vibration sense and proprioception)
  • Weakness 
  • Hematologic effects: leukopenia, thrombocytopenia, megaloblastic anemia

Management

  • Cessation of nitrous oxide use
  • Vitamin B12 (cyanocobalamin) repletion (IM)

Show References


Category: Critical Care

Title: Atrial Fibrillation in Critically Ill Patients

Keywords: Atrial Fibrillation, sepsis, critical care, cardioversion, beta blockers, calcium channel blockers, rate control, rhythm control (PubMed Search)

Posted: 9/3/2019 by Robert Brown, MD (Updated: 10/18/2019)
Click here to contact Robert Brown, MD

Takeaways

One third of your critically ill patients will have atrial fibrillation. 

More than one third of those patients will develop immediate hypotension because of it.

More than one in ten will develop ischemia or heart failure because of it.

This is what you should know for your next shift:

#1 Don't wait to use electricity. If your patient is hypotensive or ischemic because of atrial fibrillation, you do not need to wait for anticoagulation before you cardiovert.

#2 Electricity buys you time to load meds. Fewer than half of patients you cardiovert will be in sinus rhythm an hour later and fewer than a quarter at the end of a day.

#3 There is no perfect rate control agent. Beta blockers have a lower mortality in A-fib from sepsis. Esmolol has the benefit of being short-acting if you cause hypotension. Diltiazem has better sustained control than amiodarone or digoxin. 

#4 There is no perfect rhythm control agent. Magnesium is first-line in guidelines. Amiodarone can be used even when there is coronary artery or structural heart disease.

#5 Anticoagulation is controversial. In sepsis, anticoagulation does not reduce the rate of in-hospital stroke, but does increase the risk of bleeding. Use with caution if cardioversion isn't planned.

 

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There is no standardized national reporting of dog bites in the US. Based on the reported figures, it is estimated that 2% of Americans are bitten annually, and children are affected disproportionately. With kids, it's usually the family dog, and occurs at home.

To avoid infection, usually from Pasturella species, many of us were taught never to primarily repair dog bites by suturing, and to always prescribe prophylactic antibiotic coverage with amoxicillin-clavulanate. However, the literature recommends otherwise in certain cases.

Bite wounds to the face and hands should have special considerations.  In general, face wounds heal with lower rates of infection, but provide the greatest concern for cosmetic appearance.  Hand wounds have notoriously higher rates of infection.  

The latest recommendations for dog bites are as follows:

1. All dog bites should be copiously irrigated under high pressure.

2. Dog bites to the face should be primarily repaired when <8 hours old, as infection rates are not significantly different and cosmesis is greatly improved. 

3. Injuries to the hands should be left open, unless function is in jeopardy or there are neurovascular concerns.

4.  Prophylactic antibiotics do not always have to be prescribed, especially in low risk patients.  Examples of high risk patients include, but are not limited to: primarily repaired bites, injuries in the hand, >8 hours old, deep or macerated or multiple bites, and the immunocompromised.

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