Category: Critical Care
Systematic review and meta-analysis of 5 studies with a total of 929 patients comparing early vs. late initiation of norepinephrine in patients with septic shock
Take home point:
Early norepinephrine usage may improve mortality in septic shock
Li Y, Li H, Zhang D. Timing of norepinephrine initiation in patients with septic shock: a systematic review and meta-analysis. Crit Care. 2020;24(1):488.
Keywords: prepubertal vaginal bleeding, mass (PubMed Search)
- Urethral prolapse will appear as a protrusion of the distal urethra through the urinary meatus causing a “doughnut” sign.
- Risk factors include trauma, UTI, anatomical differences, and increased intraabdoiminal pressure from cough or constipation. There is a higher incidence in people of African descent.
- The chief complaint may include urethral mass and vaginal bleeding.
- There is a bimodal age distribution (prepuberty and postmetapause) due to a relative estrogen deficiency.
-Treatment is with estrogen cream and sitz baths for 4- 6 weeks.
McCaskill A, Inabinet C, Tomlin K et al. Prepubertal Genital Bleeding: Examination and Differential Diagnosis in Pediatric Female Patients. The Journal of Emergency Medicine 2018; 55(4): 97-100.
Keywords: Spine fracture, decision rule (PubMed Search)
A recent study looked at thoracic spinal fractures in the era of the trauma panscan
NEXUS Chest CT Study from 2011 to 2014 at 9 Level I trauma centers.
Goal: To describe the identification rate and types of thoracic spine fractures.
Inclusion: age over 14 years, blunt trauma occurring within 6 hours of ED presentation, and chest CT imaging during ED evaluation.
11,477 subjects, 217 (1.9%) had a thoracic spine fracture
The majority of spine fractures in patients who had both chest x-ray and CT were observed on CT only (91%). 50% had more than 1 thoracic spinal level involved (mean 2.1). 22% had associated cervical fractures and 25% had associated lumbar fractures.
64% had vertebral body fractures
45% had posterior column fractures
28% had compression fractures
6% had burst fractures
Many patients (62%) had associated thoracic injuries such as
Rib fractures (45%)
Clavicle fracture (18%)
Scapular fracture (17%)
100 patients had clinically significant thoracic spine fractures.
Thoracic spine fractures are relatively uncommon in adult patients with blunt trauma.
If thoracic spine fracture is suspected clinically, radiography is not an effective screen and clinician should consider CT. If not suspected, guidelines discourage ordering CT to screen for this injury because of effective screening instruments, the diagnosis of clinically insignificant injuries and radiation exposure.
All clinically significant thoracic spine fractures would have been detected by the NEXUS Chest CT decision instrument.
Bizimungu R, Sergio Alvarez, Baumann BM, et al. Thoracic Spine Fracture in the Panscan Era. Ann Emerg Med. 2020;76(2):143-148.
Keywords: ECMO, poisoning, trend in US (PubMed Search)
Extracorporeal membrane oxygenation use is increasing in the US for acute poisoning.
A retrospective study of the National Poison Data System from 2000 to 2018 identified 407 ECMO cases (332 adults – age > 12 years, 75 pediatric – age < 12 years). Increase in ECMO use were more notable in adult population.
Most common class of drug/poison exposure in adults
Most common class of drug/poison exposure in children
Most common states that used ECMO for poisoning
Keywords: cerebral venous thrombosis, CVT, prothrombotic, headache (PubMed Search)
Bottom Line: The incidence of CVT is increasing with rate of increase higher in males and older females. Consider CVT beyond traditional risk factors.
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Category: Critical Care
Keywords: resuscitation, ultrasound, VExUS, venous congestion (PubMed Search)
While the invasive monitoring of central venous pressure (CVP) in the critically ill septic patient has gone the way of also transfusing them to a hemoglobin of 10 mg/dL, it remains that an elevated CVP is associated with higher mortality1,2 and renal failure.2,3
Extrapolating from existing data looking at hepatic vein, portal vein, and renal vein pulsatility as measures of systemic venous hypertension and congestion,4,5,6 Beaubien-Souligny et al. developed the venous excess ultrasound (VExUS) grading system incorporating assessment of all 3, plus the IVC, using US to stage severity of venous congestion in post-cardiac surgery patients.7 They evaluated several variations, determining that the VExUS-C grading system was most predictive of subsequent renal dysfunction.
(Image from www.pocus101.com)
VExUS Grade 3 (severe) venous congestion:
A great how-to can be found here:
1. Li DK, Wang XT, Liu DW. Association between elevated central venous pressure and outcomes in critically ill patients. Ann Intensive Care. 2017;7(1):83. doi:10.1186/s13613-017-0306-1
2. Chen KP, Cavender S, Lee J, et al. Peripheral Edema, Central Venous Pressure, and Risk of AKI in Critical Illness. Clin J Am Soc Nephrol. 2016;11(4):602-608.
3. Chen CY, Zhou Y, Wang P, Qi EY, Gu WJ. Elevated central venous pressure is associated with increased mortality and acute kidney injury in critically ill patients: a meta-analysis. Crit Care. 2020;24(1):80. doi:10.1186/s13054-020-2770-5
4. Iida N, Seo Y, Sai S, et al. Clinical Implications of Intrarenal Hemodynamic Evaluation by Doppler Ultrasonography in Heart Failure. JACC Heart Fail. 2016;4(8):674-682. doi:10.1016/j.jchf.2016.03.016
5. Ikeda Y, Ishii S, Yazaki M, et al. Portal congestion and intestinal edema in hospitalized patients with heart failure. Heart Vessels. 2018;33(7):740-751. doi:10.1007/s00380-018-1117-5.
6. Beaubien-Souligny W, Benkreira A, Robillard P, et al. Alterations in Portal Vein Flow and Intrarenal Venous Flow Are Associated With Acute Kidney Injury After Cardiac Surgery: A Prospective Observational Cohort Study. J Am Heart Assoc. 2018;7(19):e009961. doi:10.1161/JAHA.118.009961
7. Beaubien-Souligny W, Rola P, Haycock K, et al. Quantifying systemic congestion with Point-Of-Care ultrasound: development of the venous excess ultrasound grading system. Ultrasound J. 2020;12(1):16. doi:10.1186/s13089-020-00163-w
Category: Pharmacology & Therapeutics
Keywords: esmolol, cardiac arrest, ventricular tachycardia, ventricular fibrillation (PubMed Search)
| || |
Temporary ROSC, n (%)
OR 14.46, 95% CI 3.63-57.57
Sustained ROSC, n (%)
OR 5.76, 95% CI 1.79-18.52
Survival with neurological function, n (%)
OR 4.42; 95% CI 1.05-18.56
Keywords: button battery, pediatrics, esophageal injuries (PubMed Search)
Ingestion of a button battery is a can't-miss diagnosis with a very high risk for causing severe esophageal injury. There are about 3000 button battery ingestions per year, and this is increasing because electronics are becoming more and more prevalent.
Severe damage to the esophagus occurs within 2 hours. On your lateral view, the end with narrowing is the negative end, which triggers a hydrolysis reaction that results in an alkaline caustic injury and, ultimately, liquefactive necrosis.
Children can present with nonspecific symptoms and if the ingestion was not witnessed, they are at high risk for delays in diagnosis. Additionally, in the community setting, there can be further delays in definitive treatment (endoscopic removal) due to difficulty in calling teams in or transporting to other facilities.
Anfang et al. looked into ways to mitigate damage to esophageal tissue. They did an in vitro study on porcine esophageal tissue, measuring the pH with different substances applied. They tried apple juice, orange juice, gatorade, powerade, pure honey, pure maple syrup, and carafate. They then repeated the study in vivo on piglets with button batteries left in the esophagus and ultimately did gross and histological examination of the esophageal tissue.
Honey and carafate demonstrated protective effects both in vitro and in vivo. They neutralized pH changes, decreased full-thickness esophageal injury, and decreased outward extension of injury into deep muscle.
Take Home Point: If a child is found to have a button battery in the esophagus, while definitive management is still emergent endoscopic removal, early and frequent ingestion of honey (outside of the hospital) and Carafate (in the hospital) may help reduce the damage done to the tissue in the interim. The authors recommend 10ml every 10 minutes.
Anfang RR, Jatana KR, Linn RL, et al. pH-Neutralizing Esophageal Irrigations as a Novel Mitigation Strategy for Button Battery Injury. The Laryngoscope. 2019; 129:49-57.
Category: Critical Care
Keywords: Renal Replacement Therapy (PubMed Search)
The Standard versus Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury
The development of acute kidney injury (AKI) in the critical care setting portends a greater morbidity and mortality for patients. Additionally, it places the patient at high risk of complications and requires a greater use of resources. Several studies in the past have examined if the timing of initiation of renal replacement therapy (RRT) would result in a mortality benefit, but have failed to demonstrate consistent outcomes.
The STARRT-AKI trial was a multinational, randomized controlled trial designed to determine if early initiation of RRT in critically ill adult patients with AKI lowered the risk of 90-day mortality. The Kidney Disease Improving Global Outcomes (KDIGO) classification was used to define AKI and over 2900 patients were randomly assigned to two groups over a 4 year period. Exclusion criteria included: recent RRT, a renal transplant within the preceding year, advanced CKD, an overdose necessitating RRT, or a strong suspicion of obstruction or autoimmune/vascular cause of their AKI.
Take home points:
Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury. STARRT-AKI Investigators; Canadian Critical Care Trials Group, the Australian and New Zealand Intensive Care Society Clinical Trials Group, the United Kingdom Critical Care Research Group, the Canadian Nephrology Trials Network, and the Irish Critical Care Trials Group, Bagshaw SM, Wald R, Adhikari NKJ, et al. N Engl J Med. 2020 Jul 16;383(3):240-251.
Keywords: trigeminal neuralgia, TN, tic douloureux, neuropathic facial pain (PubMed Search)
Bottom Line: New onset trigeminal neuralgia needs workup for its etiology. Carbamazepine and oxcarbazepine can be effective for symptom management though continuous or long-lasting pain exacerbations are difficult to treat.
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Category: Critical Care
Ketamine In the Critically Ill Patient
Hurth KP, et al. The reemergence of ketamine for treatment in critically ill adults. Crit Care Med. 2020; 48:899-911.
Keywords: Elbow, fracture, ultrasound (PubMed Search)
Diagnostic performance of Ultrasonography for detection of pediatric elbow fracture
Elbow fractures account for approximately 15% of pediatric fractures
Fat pads are traditionally taught as a marker of fracture
In a cadaveric study:
Elbow effusions of 1-3 mL could be identified with ultrasound
Elbow effusions of 5-10 mL could be identified with plain film
Pediatric plain films are sometimes challenging to obtain and interpret compared to adults
-More likely to be uncooperative in obtaining required views
Ultrasound may be used to detect
-Cortical disruption and irregularity
-Growth plate widening
-Hematoma interposed between fracture fragments
-Elevated posterior fat pad
Absence of elbow fracture was indicated by
-Lack of cortical disruption
-Absence of posterior fat pad sign
Meta-analysis of 10 articles totaling 519 patients using ultrasonography to detect elbow fractures
False negative rate 3.7%
For comparison, plain radiographs
Interpreted by peds EM physicians (87.5% sensitive and 100% specific)
Interpreted by radiology (96% sensitive, 100% specific)
Consider using ultrasound as a noninvasive, radiation-free modality for accurate diagnosis of pediatric elbow fractures.
Lee SH, Yun SJ. Diagnostic Performance of Ultrasonography for Detection of Pediatric Elbow Fracture: A Meta-analysis. Ann Emerg Med. 2019;74(4):493-502.
Keywords: Female GU, abdominal pain, missed period (PubMed Search)
Definition: Congenital anomaly where the hymen is completely obstructing the vaginal opening
Demographic: Incidence 0.05-0.1% of females
History: Most are asymptomatic and diagnosed on physical exam or incidentally when there is lack of menarche. Symptoms in adolescents can include: Abdominal pain (50%), urinary retention (20%), abnormal menstruation (14%), dysuria (10%), frequency, renal failure, UTI and back pain.
Physical exam: bulging, blueish hymenal membrane
Complications: Late detection can lead to infections, fertility problems, endometriosis, hydronephrosis, and rarely renal failure
ED treatment: If abdominal pain is significant or there is urinary obstruction, a urinary foley can be placed. GYN should be consulted.
Definitive treatment: Hymenectomy, hymenotomy, carbon dioxide laser treatments or foley insertion through the hymen (done by a specialist).
Lee K, Hong J, Jung H et al. Imperforate Hymen: A Comprehensive Systematic Review. J Clin Med 2019; 8(56): 1-14.
Keywords: baclofen overdose, hemodialysis, renal elimination (PubMed Search)
Baclofen is a presynaptic GABA-B receptor agonist in the spinal cord that is primarily used for muscle spasms/spasticity. In large overdose, baclofen can produce CNS depression, respiratory depression, bradycardia/hypotension, hypothermia, seizure and coma.
Baclofen is primarily eliminated by the kidney. In patients with end-stage kidney disease/acute kidney failure, hemodialysis (HD) has been used to enhance baclofen clearance. However, it is unclear if there is a benefit of using HD in patients with normal kidney function.
In a recently published case report, HD was implemented in an attempt to shorten the anticipated prolonged ICU course.
Case: 14 year old (51 kg) woman ingested 60 tablets of baclofen (20 mg tablets)
Her symptoms were:
Baclofen level: 882 ng/mL (therapeutic range: 80 – 400 ng/mL)
Baclofen clearance from hemodialysis vs. urine
Patient’s mental status improved on hospital day 6 and was extubated. She was discharged to psychiatry on hospital day 14.
Lee VR et al. Removal of baclofen with hemodialysis is negligible compared to intact kidney excretion in a pediatric overdose: a case report. Clin Toxicol. 2020
Category: Critical Care
Keywords: COVID-19, ARDS, Pneumonia, Steroids (PubMed Search)
Another week, another COVID-19 study...
On August 12th, the Metcovid study was e-published ahead of print in Clinical Infectious Diseases. This was another study looking at steroids in COVID-19 pneumonia, this time performed in Brazil. Metcovid was a parallel, double-blind, randomized, placebo-controlled phase IIb clinical trial which enrolled 416 patients at a single academic center for the evaluation of methylprednisolone (MP; 0.5 mg/kg BID x 5 days) vs placebo. As with all COVID studies, Metcovid has some significant limitations, and some equivocal findings. However, Metcovid was largely in line with RECOVERY and other trials looking at steroids in COVID-19, which lends it some face validity. Metcovid found no significant difference in the primary outcome (mortality at day 28), but did find a difference in mortality in patients over 60 years old (a post-hoc analysis). Metcovid was probably underpowered (sample size was based on a 50% reduction in mortality), and did have a very small trend towards reduced mortality in the MP group (37.1% vs 38.2%, p=0.629).
Keywords: nitrous oxide abuse, neurologic findings, physical exam (PubMed Search)
What physical exam findings are associated with nitrous oxide abuse?
Nitrous oxide (NO) inhalation abuse, also called “whip-its” or “whippets”, inactivates vitamin B12 and create a vitamin B12 deficiency state. Chronic abuse of nitrous oxide can result in neurologic deficits/findings affecting the posterior/dorsal column of the spinal cord.
Physical exam findings:
Keywords: cerebrospinal fluid, rhinorrhea, otorrhea, halo, double ring, beta-2 transferrin (PubMed Search)
Bottom Line: Beta-2 transferrin is more accurate than the halo sign to identify CSF containing fluid.
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Keywords: Peripheral neuropathy, median nerve (PubMed Search)
Pronator Teres Syndrome
A compressive neuropathy of the median nerve in the region of the elbow
The median nerve passes through the cubital fossa and passes between the superficial and deep heads of the pronator teres muscle.
Rare compared to other compressive neuropathies such as carpal tunnel syndrome.
More common in women and in fifth decade of life
May be seen with weight lifters, arm wrestlers, rowers, tennis, archery, professional cyclists, dentists, fiddlers, pianists, harpists
Also associated with well-developed forearm muscles
Forearm pain – unlike carpal tunnel
Paresthesias in median distribution
No night symptoms – unlike carpal tunnel
Sensory loss in medial nerve distribution.
Involves the thenar eminence!
Unlike carpal tunnel syndrome which doesn’t involve sensory loss in thenar eminence.
Pain may be made worse with resisted forearm pronation
Compression/Tinel’s sign over pronator mass reproduces symptoms
Splinting which limits pronation and NSAIDs
Surgical nerve decompression is non operative treatment fails after greater than 6 months (rare)
Category: Critical Care
Keywords: gastrointestinal bleeding, TXA (PubMed Search)
Prior to this study, a Cochrane review and meta-analysis of TXA for upper GI bleeds with 7 trials (1654 patients), showed a large reduction in mortality with TXA (RR 0.61, 95% CI 0.42-0.98, p=0.01)
-Randomized, international, multicentre, placebo-controlled trial at 164 hospitals in 15 countries Juy 2013-2019
->16/18 years old with upper or lower GI bleeding
-1 g TXA IV over 10 minutes followed by maintenance dose 3 g TXA over 24 hours
-Main outcome death due to bleeding within 5 days
-4% (222/5994) died in TXA group vs 4% (226/5981) placebo risk ratio RR 0.99, 95% CI 0.82-1.18
-Arterial thromboembolic events MI/CVA similar in both groups (0.7% vs 0.8%)
-Venous thromboembolic events PE/DVT higher in TXA group (0.8% vs 0.4%)
-Initially calculated all cause mortality until realization that over half deaths were due to non-bleeding causes, changed to death related to bleeding, allowing study appropriate power to detect difference
-Majority of patients had UGIB/variceal bleeding due to liver disease, over 75% deaths in those with liver disease
-Only 16% patients randomized in <3 hours, most >8 hours (CRASH-2 trial found benefit TXA in trauma patients only <3 hrs to administration)
-TXA should not be used in the management of GI bleeds
-Increased venous thromboembolic events associated with TXA administration for GI bleeds
HALT-IT Trial Collaborators. Effects of a high-dose 24-h infusion of tranexamic acid on death and thromboembolic events in patients with acute gastrointestinal bleeding (HALT-IT): an international randomised, double-blind, placebo-controlled trial. Lancet. 2020;395(10241):1927-1936. doi:10.1016/S0140-6736(20)30848-5
Gluud LL, Klingenberg SL, Langholz E. Tranexamic acid for upper gastrointestinal bleeding. Cochrane Database Syst Rev. 2012;1
Category: Pharmacology & Therapeutics
Keywords: Cirrhosis, Pain, Acetaminophen, NSAID, Opioid (PubMed Search)
The liver performs an essential role in the metabolism and clearance of many drugs. Liver damage due to cirrhosis can decrease first-pass metabolism of oral medications and increase free-drug concentrations of protein-bound medications due to decreased albumin production. In the absence of cirrhosis, patients with chronic hepatitis or hepatic cancer may only have a small decrease in drug clearance. Hepatic dose adjustments are not as prevalent or readily available as renal dose adjustments, which can create difficulty in finding the balance between pain relief and adverse effects.
The most common medications used for pain control in the emergency department are acetaminophen, NSAIDs, and opioids.
It is sometimes misconceived that acetaminophen should never be used in patients with cirrhosis due to the common knowledge that acetaminophen overdoses can cause hepatotoxicity. Alcoholics may have an increased risk of hepatotoxicity due to induction of CYP2E1 and decreased glutathione stores. However, acetaminophen is safe in patients with cirrhosis when used at appropriate doses. Limit the total daily dose of acetaminophen to 2 g daily in patients with cirrhosis and avoid acetaminophen in patients that are actively drinking. Also, educate patients that over-the-counter (OTC) and prescription medications may contain acetaminophen.
In patients with cirrhosis, NSAIDs have increased bioavailability due to decreased CYP metabolism and decreased protein binding. In addition, prostaglandin inhibition can precipitate renal failure and sodium retention, worsening ascites and increasing the risk of hepatorenal syndrome, and increase the risk of gastrointestinal bleeding. Thrombocytopenia from NSAID use can further increase the risk of bleeding. Thus, avoid NSAID use in patients with cirrhosis. Topical NSAIDs can be considered.
Opioid metabolism is altered in patients with cirrhosis and can contribute to complications with cirrhosis, such as precipitating encephalopathy. Generally, the bioavailability is increased and half-life is extended; thus, lower doses of immediate-release (IR) formulations at extended dosing intervals should be utilized. Common opioids for acute pain control in the emergency department are fentanyl, hydrocodone/oxycodone, hydromorphone, and morphine.
Take Home Points
Max daily dose 2 g/day
Avoid if actively drinking. Be cautious if patient also taking OTC or combination products.
Topical NSAIDs may be considered.
Start with IR products at lower doses and extended intervals.
1. Rakoski M, Goayl P, Spencer-Safier M, Weissman J, Mohr G, Volk M. Pain management in patients with cirrhosis. Clinical Liver Disease. 2018;11:135-140.
2. Wehrer M. Pain management considerations in cirrhosis. US Pharm. 2015;40:HS5-HS11.