Keywords: Head injury mannitol saline ICP (PubMed Search)
"The main findings were the following: (1) there was no evidence of an effect of HTS compared with other agents (mainly mannitol) on long-term neurological outcome in patients with raised ICP; (2) similarly, there was no evidence of a beneficial effect of HTS on all-cause mortality, uncontrolled ICP, length of hospital or ICU stay, and ICP reduction; and (3) HTS may be associated with increased risk of adverse hypernatremia.”
Bernhardt, K., McClune, W., Rowland, M.J. et al. Hypertonic Saline Versus Other Intracranial-Pressure-Lowering Agents for Patients with Acute Traumatic Brain Injury: A Systematic Review and Meta-analysis. Neurocrit Care (2023). https://doi.org/10.1007/s12028-023-01771-9
Keywords: foreign body ingestion, magnet (PubMed Search)
Kids eat everything (except perhaps carefully prepared and balanced meals). While button battery ingestions are feared, there is more to worry about. Magnet ingestions – especially rare earth metal magnet ingestions – can lead to high morbidity and mortality.
When more than one magnet (or a magnet and another metallic object) are ingested, they can become stuck together through walls in the GI tract, creating risk for obstruction, erosion, fistula formation, and perforation. Sharp metallic foreign objects can be particularly dangerous as they can do much damage while being moved around by the magnet.
If there is concern for magnet ingestion, care should be taken to try to determine the number ingested (if parents have the magnets, you can compare the size of an object on xray to the size of the magnets as it can otherwise sometimes be difficult to differentiate if it is one magnet or more than one stuck together).
Higher risk features of ingestion include:
Ingestions should prompt consultation with pediatric GI and surgery when isolated as many will require either endoscopic or surgical removal. This may include need for referral and transfer.
Nugud AA, Tzivinikos C, Assa A, et al. Pediatric Magnet Ingestion, Diagnosis, Management, and Prevention: A European Society for Paediatric Gastroenterology Hepatology and Nutrition (ESPGHAN) Position Paper. Journal of pediatric gastroenterology and nutrition. 2023;76(4):523-532.
Keywords: Workforce, Diversity, Under-represented minorities (PubMed Search)
Physician Workforce Diversity in EM
Health inequities along racial, ethnic, and socioeconomic lines are a brutal reality of the current state of health care in the US. One way to attempt to address these inequities is to make a concerted effort to diversify our physician workforce. As authors have noted, “Having physicians from diverse backgrounds as colleagues and role models can promote understanding and tolerance in nonminority physicians, ultimately improving medical care for patients who are part of these racial and ethnic groups. Increasing the population of underrepresented minority (URM) physicians in the workforce also directly improves health care for medically underserved populations from all racial and ethnic backgrounds, as studies have shown that physicians from URM backgrounds are more likely to work with these patients.”
Administrators are often tasked with the difficult job of creating a cohesive group of emergency physicians to meet the needs of the community they serve. Strategies to diversify that workforce would benefit from a multi-level approach, including the following:
Small steps can create big changes.
Keywords: Neutropenic Fever, Phamacology, Infectious Disease, Oncology (PubMed Search)
Treatment of neutropenic fever is evolving, especially in the context of multidrug-resistant (MDR) organisms. This article reviews an update on best practices and describes two approaches to antimicrobial therapy- "escalation" and "de-escalation". Escalation begins with a narrow spectrum of antimicrobials and increases based on patient response, suitable for uncomplicated cases. De-escalation starts with broad-spectrum antibiotics and narrows down, recommended for complicated cases. The choice depends on the institution's MDR prevalence. Initial antimicrobials like cefepime or carbapenems are selected based on resistance rates. De-escalation timing varies per guidelines, but clinical trials support its safety and efficacy. Benefits include reducing C. difficile risk, antimicrobial resistance, and complications. Despite these advantages, some centers lack explicit de-escalation guidance, emphasizing the need for clear protocols to optimize patient outcomes by minimizing antibiotic therapy duration.
Molina KC. Best Practices in the Management of Infectious Complications for Patients With Cancer: Management of Febrile Neutropenia. J Adv Pract Oncol. 2023 Apr;14(3):201-206. doi: 10.6004/jadpro.2023.14.3.4. Epub 2023 Apr 1. PMID: 37197726; PMCID: PMC10184844.
Keywords: asthma, reactive airway disease, lung function (PubMed Search)
The role of exercise in patients with asthma is complicated.
Asthma symptoms can worsen or be triggered by physical activity. This can lead to avoidance response. Patients with asthma are less physically active than their matched controls.
Recently, however, the role of exercise and physical activity as an adjunct therapy for asthma management has received considerable attention. There is an emerging and promising role of physical activity as a non-pharmacologic treatment for asthma. Exercise reduces inflammatory cytokines and increases anti-inflammatory cytokines thereby reducing chronic airway inflammation.
Physical activity can help improve lung function and boost quality of life. As fitness improves, asthma patients report better sleep, reduced stress, improved weight control, and more days without symptoms.
The Global Initiative for Asthma recommends twice-weekly cardio and strength training. Strength training requires short periods of exertion allowing for periods of rest and recovery. High-intensity interval training (HIIT) is a promising option for people with asthma. These types of workouts allow ventilation to recover intermittently vs conventional cardio exercises.
A 2021 study in adults with mild-to-moderate asthma found that low volume HIIT classes (three 20-minute bouts/week) significantly improved asthma control. Patients also had improved exertional dyspnea and enjoyment of exercise which will, in turn, increase the odds of further exercise.
A 2022 study compared constant-load exercise versus HIIT in adults with moderate-to-severe asthma. Exercise training lasted 12 weeks (twice/week, 40 minutes/session). Both groups showed similar improvements in aerobic fitness however the HIIT group reported lower dyspnea and fatigue perception scores and higher physical activity levels.
Conclusion: Patients with asthma should be encouraged to safely incorporate exercise in their daily lives bother for overall health benefits but also as an effective non-pharmacologic asthma treatment.
1. O'Neill C, Dogra S. Low volume high intensity interval training leads to improved asthma control in adults. J Asthma. 2021 Sep;58(9):1256-1260.
2. Aparecido da Silva R, Leite Rocco PG, Stelmach R, Mara da Silva Oliveira L, Sato MN, Cukier A, Carvalho CRF. Constant-Load Exercise Versus High-Intensity Interval Training on Aerobic Fitness in Moderate-to-Severe Asthma: A Randomized Controlled Trial. J Allergy Clin Immunol Pract. 2022 Oct;10(10):2596-2604
Keywords: DEI, social Z codes (PubMed Search)
Since the switch from fee for service to value based care in the US, there has been a marked push to improve our documentation to expand our MDM and differential considerations. We are all here becoming adept at the medical documentation (thanks Dr. Adler!), but may not be adequately documenting our patients' social determinants of health using the social Z codes, a subset of ICD-10 coding language
This study wanted to look at the overall prevelance of social Z code utilization. They used the Nationwide Emergency Department Sample (NEDS), a nationwide database of ED visits, to look at this particular documentation. They examined 35 million (!) ED visits and found that only 1.2% had any social Z code included in the documentation. Given how many resources are linked to a verified (eg documented) need, this raises the idea that if Z codes are better documented, this may lead to increased funding for things like food, housing and transportation insecurities.
Limitations- the authors only examined the ED visits for ICD-10 codes, they didn't specifically look at the notes themselves which may have contained SDOH information. They also found that the social Z codes were more often documented in visits coded for mental health diagnoses, potentially indicating bias. There is also the concern that patients may not want the social z codes included, given the stigma around things like homelessness.
Overall, social Z code documentation could potentially unlock better resources for our patients by documenting a specific need in a population. More will come as documentation continues to evolve.
Molina, MF, et al. Social Risk Factor Documentation in Emergency Departments. Annals of Emergency Medicine, Vol 81, No. 1; January 2023. p38-46
Keywords: cardiac arrest, CPR, bystander (PubMed Search)
Ko YC, Hsieh MJ, Schnaubelt S, Matsuyama T, Cheng A, Greif R. Disparities in layperson resuscitation education: A scoping review [published online ahead of print, 2023 Jul 25]. Am J Emerg Med. 2023;72:137-146. doi:10.1016/j.ajem.2023.07.033
Category: Critical Care
Keywords: BRASH, shock, av nodal blockers (PubMed Search)
The BRASH syndrome (Bradycardia, Renal failure, AV nodal blockade, Shock, Hyperkalemia) has been increasingly described in the literature in the past 3-5 years.
The inciting factor is generally considered to be something that prompts acute kidney injury, often hypovolemia of some sort. Rather than AV nodal blocker overdose or severe hyperkalemia causing conduction problems, the combination of AV nodal blocker use (most often beta-blockers, but can be any type) and hyperkalemia (often only moderate) has a synergistic effect on cardiac conduction with ensuing bradycardia that can devolve into a cycle of worsening renal perfusion and shock.
Treatment is supportive, but most effective when the syndrome is recognized and all parts simultaneously managed. ED physicians should be familiar with its existence for targeted whole-syndrome stabilization and to avoid diagnostic delay.
Keywords: POCUS (PubMed Search)
Point of Care Ultrasound has been shown to change medical management and decrease time to diagnosis.
However, sometimes on a busy shift we may get an xray or radiological study prior to performing a POCUS exam due to time constraints.
A recent study looked at the time it takes to perform a bedside ultrasound.
The authors measured the duration of time from starting the exam through the ultrasound worklist to the timestamp on the last recorded image.
They reviewed 2144 studies and found a median time of 6 minutes to perform a study.
Of course the study is limited by the time it takes to find a machine, make sure it is functioning and other supplies such as gel.
Conclusion: You can take 6 minutes to assist in your patient's clinical care.
Patrick DP, Bradley XG, Wolek C, Anderson B, Grady J, Herbst MK. Minutes matter: Time it takes to perform point-of-care ultrasound. AEM Educ Train. 2023 Aug 18;7(4):e10901. doi: 10.1002/aet2.10901. PMID: 37600853; PMCID: PMC10436032.
Keywords: appendicitis, delayed operating room, appendectomy (PubMed Search)
This Scandinavian study from the Lancet says yes. They randomized 1800 patients over age 18 to appendectomy either within 8 hours or 24 hours and found no difference in perforation rate or other complications.
Karoliina Jalava, Ville Sallinen, Hanna Lampela, Hanna Malmi, Ingeborg Steinholt, Knut Magne Augestad, Ari Leppäniemi, Panu Mentula,
Role of preoperative in-hospital delay on appendiceal perforation while awaiting appendicectomy (PERFECT): a Nordic, pragmatic, open-label, multicentre, non-inferiority, randomised controlled trial,
The Lancet, 2023
Keywords: Spontaneous Pneumomediastinum, asthma, crepitus, esophagram (PubMed Search)
Roby K, Barkach C, Studzinski D, Novotny N, Akay B, Brahmamdam P. Spontaneous Pneumomediastinum is Not Associated With Esophageal Perforation: Results From a Retrospective, Case-Control Study in a Pediatric Population [published online ahead of print, 2023 Apr 23]. Clin Pediatr (Phila). 2023;99228231166997. doi:10.1177/00099228231166997
Category: Pharmacology & Therapeutics
Keywords: DOAC, apixaban, rivaroxaban, loading dose (PubMed Search)
DOACs (dabigatran*, apixaban, rivaroxaban) each have different dosing strategies based on indication and patient characteristics. While there is no official term for the doses, the higher initial doses for apixaban (10 mg BID for 7 days) and rivaroxaban (15 mg BID for 21 days) for the treatment of venous thromboembolism (VTE) are commonly referred to as “loading doses.” However, the term “loading dose” is actually a misnomer.
Loading doses are used to reach therapeutic drug levels quicker with medications such as vancomycin and phenytoin/fosphenytoin. However, this is not the purpose of the higher initial doses of apixaban and rivaroxaban. The purpose of the higher doses is to provide increased levels of anticoagulation during the acute phase of VTE when patients are hypercoagulable. For this reason, VTE and heparin-induced thrombocytopenia are the only indications where a higher dose is used initially, all other indications start with the standard dose. The difference in duration of these higher doses between apixaban (7 days) and rivaroxaban (21 days) are due to the durations used in trials by the drug company, versus any pharmacokinetic reasons.
To apply this concept:
Apixaban/Rivaroxaban: For the treatment of VTE, a higher dose is only required for the initial 7- (apixaban) or 21-day period (rivaroxaban). After this period, if there is any interruption in therapy, the standard dose can be restarted because therapeutic levels are rapidly achieved and higher doses are not needed outside of the acute phase.
One caveat to this would be if the patient developed a new VTE while therapy is interrupted, in which case another period of the higher dosing could be considered.
*Remember: Dabigatran cannot be used for initial treatment of VTE and must be started only after at least 5 days of a parenteral anticoagulant. (Dabigatran and the parenteral anticoagulant should not be overlapped).
Eliquis (apixaban) [prescribing information]. Princeton, NJ: Bristol-Myers Squibb Company; April 2021.
Pradaxa (dabigatran) [prescribing information]. Ridgefield, CT: Boehringer Ingelheim Pharmaceuticals Inc; June 2021.
Xarelto (rivaroxaban) [prescribing information]. Titusville, NJ: Janssen Pharmaceuticals Inc; February 2023.
Category: Critical Care
Keywords: NIPPV, CPAP, HFNC, High Flow, Respiratory Failure (PubMed Search)
When patients fail simple respiratory support therapies like nasal cannula or non-rebreather, it is often a point of debate whether to move next to High Flow Nasal Cannula (HFNC) or Noninvasive Positive Pressure Ventilation (NIPPV). This study randomized patients in acute respiratory failure (ARF) to CPAP, a form of NIPPV, vs HFNC. They looked at all comers in ARF, and primary outcome was need for intubation. Importantly, they excluded asthma/COPD exacerbation, for which BiPAP is typically considered the first line therapy due to improved CO2 clearance.
They found a significantly lower number of patients required intubation in the CPAP (28.9%) group than the HFNC (42.6%) group (p=0.006). They hypothesized that the enhanced PEEP improved oxygenation (hypoxia being a common trigger for moving to intubation), but as opposed to BiPAP, the lack of additional driving pressure limited tidal volumes and Patient Self-Inflicted Lung Injury (P-SILI), which is a known mechanism of ARDS and mortality. They use this argument to explain why trials like FLORALI, pitting HFNC vs BiPAP, tend to not find an advantage for the NIPPV arm. While this rationale makes sense, it should be noted that the study does not directly investigate if this was the reason for the difference, and for what its worth the inverse argument that using driving pressure to reduce respiratory rate, hypercarbia, and work of breathing (other very common indications for intubation) would also theoretically reduce intubations. Furthermore, it's not clear why reducing P-SILI, which tends to cause mortality on a much longer duration, would improve the short-term outcome of need for intubation.
Bottom Line: This study demonstrated a benefit to CPAP over HFNC in terms of decreasing need for intubation amongst non-asthma/non-COPD patients with acute respiratory failure, and offered a physiologic rationale but one that requires further verification and discussion. While it may be reasonable to choose CPAP instead of HFNC in marginal patients at risk of intubation (but stable enough to trial noninvasive support first), in my opinion more studies are likely needed before a wholesale change in practice. The study also does not take into consideration the enhanced comfort and compliance we tend to see with HFNC over NIPPV, which should be considered as well.
Nagata K, Yokoyama T, Tsugitomi R, Nakashima H, Kuraishi H, Ohshimo S, Mori Y, Sakuraya M, Kagami R, Tanigawa M, Tobino K, Kamo T, Kadowaki T, Koga Y, Ogata Y, Nishimura N, Kondoh Y, Taniuchi S, Shintani A, Tomii K; JaNP-Hi Study Investigators. Continuous positive airway pressure versus high-flow nasal cannula oxygen therapy for acute hypoxemic respiratory failure: A randomized controlled trial. Respirology. 2023 Aug 30. doi: 10.1111/resp.14588. Epub ahead of print. PMID: 37648252.
Keywords: rural, trauma, laparotomy, damage control (PubMed Search)
For rural emergency departments, the decision to transfer a trauma patient to a level one center involves multiple factors including the patient’s hemodynamic stability. Harwell et al. looked at 47 trauma patients transferred from a rural hospital to a level one center. They found: “Overall mortality was significantly different between patients who had damage control laparotomy at a rural hospital (14.3%), were unstable transfer patients (75.0%), and stable transfer patients (3.3%; P < 0.001).” They concluded: “Rural damage control laparotomy may be used as a means of stabilization prior to transfer to a Level 1 center, and in appropriate patients may be life-saving.”
Preplanning with emergency medicine, surgery, radiology, anesthesia, nursing, and the receiving trauma center on how to manage these patients is critical.
Harwell PA, Reyes J, Helmer SD, Haan JM. Outcomes of rural trauma patients who undergo damage control laparotomy. Am J Surg. 2019 Sep;218(3):490-495. doi: 10.1016/j.amjsurg.2019.01.005. Epub 2019 Jan 10. PMID: 30685052.
Keywords: concussion, sports, head injury (PubMed Search)
Sport related concussion has been estimated to affect almost 2 million children and adolescents in the United states annually
Patients who take longer than four weeks to recover are considered to have persistent post concussive symptoms
This diagnosis is associated with poor educational, social and developmental outcomes in pediatric patients
Following sport related concussion, patients are recommended to have an individualized aerobic exercise program
Prior studies have found that sub symptom threshold aerobic exercise safely and significantly speeds recovery from sport related concussion.
Purpose: This study attempted to answer whether there is a direct relationship between adherence to a personalized exercise prescription and recovery or if initial symptom burden effects adherence to the prescription.
Design: Male and female adolescents aged 13 to 18 years old presenting within 10 days of injury and diagnosed with sport related concussion.
Almost all participants (94%) sustained concussion during interscholastic games or practices.
As it is known that physician encouragement can influence patient adherence to medical interventions, treating physicians in the study were blinded to study arm assignment.
Patients were given aerobic exercise prescriptions based on their heart rate threshold at the point of exercise intolerance on a graded treadmill test
Adherence to prescription was determined objectively with heart rate monitors. No participants exercised above their prescribed heart rate intensity.
Patients who completed at least 2/3 of their aerobic exercise prescription were considered to be adherent
Results: 61% of adolescents met the adherence criterion
Adherent patients were more symptomatic and were more exercise intolerant (worse initial exercise tolerance) at their initial visit.
These patients were also more adherent than those with fewer symptoms and with better exercise tolerance. This likely indicates a stronger motivation for those more symptomatic patients to engage in a potentially effective intervention.
Adherent patients recovered faster than those who were not adherent (median recovery time 12 days versus 21.5 days (P = 0.016)
Adherence during week one was inversely related to recovery time and to initial exercise tolerance but not to initial symptom severity
Conclusion: Adherence to individualized sub symptom threshold aerobic exercise within the first week of sport related concussion is associated with faster recovery. The initial degree of exercise intolerance (but not initial symptom severity) affects adherence to aerobic exercise prescription in an adolescent population with sport related concussion
Chizuk HM, et al. Adolescents with Sport-Related Concussion Who Adhere to Aerobic Exercise Prescriptions Recover Faster. Med Sci Sports Exerc. 2022 Sep 1;54(9):1410-1416.
Keywords: Pediatrics, procedures, sedation (PubMed Search)
The literature is not completely new regarding the use of intranasal dexmedetomidine for pediatric sedation, with several articles confirming noninferiority to benzodiazepines. It is a potent a2- adrenergic receptor agonist, which allows for sedation without analgesic properties. It can be considered for patients who are undergoing PAINLESS procedures. A recent article gave further clarification for dosing considerations when selecting this option. This study assessed varying weight-based doses and found the best effect with doses of 3 to 4 mcg/kg
Importantly, there is limited data that suggests this may result in longer discharge, duration of procedure and total time in the department compared to other sedation methods. Additionally, this option is not always readily available and approved for pediatric patients in every hospital.
Overall, Dexmedetomidine may be an excellent option for painless procedures, such as CT imaging or even MRI based on the literature, when available.
Poonai N, Sabhaney V, Ali S, Stevens H, Bhatt M, Trottier ED, Brahmbhatt S, Coriolano K, Chapman A, Evans N, Mace C, Creene C, Meulendyks S, Heath A. Optimal Dose of Intranasal Dexmedetomidine for Laceration Repair in Children: A Phase II Dose-Ranging Study. Ann Emerg Med. 2023 Aug;82(2):179-190. doi: 10.1016/j.annemergmed.2023.01.023. Epub 2023 Mar 3. PMID: 36870890.
Tsze DS, Rogers AP, Baier NM, Paquin JR, Majcina R, Phelps JR, Hollenbeck A, Sulton CD, Cravero JP. Clinical Outcomes Associated With Intranasal Dexmedetomidine Sedation in Children. Hosp Pediatr. 2023 Mar 1;13(3):223-243. doi: 10.1542/hpeds.2022-007007. PMID: 36810939.
Lewis J, Bailey CR. Intranasal dexmedetomidine for sedation in children; a review. J Perioper Pract. 2020 Jun;30(6):170-175. doi: 10.1177/1750458919854885. Epub 2019 Jun 27. PMID: 31246159.
It's back to school season which means back to school injuries!
Scalp lacerations often require suturing or staple closure, but what if you can close the wound without any sharps that scare the kiddos? Consider using the Hair Apposition Technique (HAT)!
What is HAT?
- A very quick and easy technique for superficial scalp laceration closure made by twisting hair on each side of the laceration and sealing the twist with a small dot of glue for primary closure.
When do I consider HAT?
- For linear, superficial lacerations that are <10cm in length
- Laceration has achieved adequate hemostasis
- Patient has hair on both sides of the laceration
What are contraindications to HAT?
- Hair strands are less than 3cm in length
- Laceration is longer than 10cm in length
- Active bleeding from laceration despite hair apposition
- Significant wound tension
- Laceration is highly contaminated
How do I perform HAT?
- Debride wound as you normally wound for any laceration
- Take approximately 5 strands of hair on one side of the laceration and twist them together to make one twisted bundle
- Take approximately 5 strands of hair directly on the other side of the laceration and twist them together to make another twisted bundle
- Then take each bundle and intertwine the two bundles until the wound edges appose.
- Place a drop of glue on the twist
- Repeat along the length of the laceration until laceration is closed
Benefits of HAT:
- Based on a RCT from Singapore that compared suturing to HAT for superficial scalp lacerations that were <10cm, patient's were more satisfied, had less scaring, lower pain scores, shorter procedure tiems, adn less wound breakdown in the HAT group compared to the sutured group.
- A follow up study by the same group also assessed cost-effectievness of HAT compared to suturing (by taking into account staff time, need for staple/suture removal, treatment of complications, materials, etc) and found that HAT saved $28.50 USD when compared to suturing.
Category: Critical Care
Pearls for the Patient in Cardiogenic Shock
Jentzer JC, et al. Advances in the management of cardiogenic shock. Crit Care Med. 2023; 51:1222-1233.
Keywords: arrest, trauma, pneumothorax, CT scan (PubMed Search)
In a study looking at 80 blunt trauma patients that died within 1 hour of arrival to a trauma center who underwent a noncontrast post mortem CT scan the following injuries were identified:
-40% traumatic brain injury
-25% long bone fracture
-25% cervical spine injury
- 18.8% moderate/large pneumothorax
-5% esophageal intubation
Blunt trauma arrest patients deserve decompression of the chest (preferred method is open with finger sweep). Intubation should be verified with end tidal CO2. Verification on arrival at the trauma center is also prudent.
Levin, Jeremy H. MD; Pecoraro, Anthony MD, MBA; Ochs, Victoria; Meagher, Ashley MD; Steenburg, Scott D. MD; Hammer, Peter M. MD, FACS. Characterization of fatal blunt injuries using postmortem computed tomography. Journal of Trauma and Acute Care Surgery 95(2):p 186-190, August 2023. | DOI: 10.1097/TA.0000000000004012
Keywords: liver laceration, trauma (PubMed Search)