Category: Critical Care
The Critically Ill Geriatric Patient with Sepsis
Khoujah D, et al. Resuscitating the critically ill geriatric emergency department patient. Emerg Med Clin N Am. 2019; 569-81.
Keywords: Playing surface, concussion (PubMed Search)
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.
Keywords: suicide attempt, adolescent, young adults, epidemiological trend (PubMed Search)
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.
Top 5 substance involved in suicide attempt
Agents associated with serious medical outcome (after 2011)
Spiller HA et al. Suicide attempts by self-poisoning in the United States among 10-25 year olds from 2000 to 2018: substances used, temporal changes and demographics. Clin Toxicol (Phila) 2019. Oct 6:1-12. doi: 10.1080/15563650.2019.1665182. [Epub ahead of print]
Category: Critical Care
Keywords: cardiac arrest, hypothermia, nonshockable rhythm (PubMed Search)
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)
A. The study used strict enrollment criteria:
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.
Lascarrou JB, Merdji H, Le Gouge A, Colin G, Grillet G, Girardie P, Coupez E, Dequin PF, Cariou A, Boulain T, Brule N, Frat JP, Asfar P, Pichon N, Landais M, Plantefeve G, Quenot JP, Chakarian JC, Sirodot M, Legriel S, Letheulle J, Thevenin D, Desachy A, Delahaye A, Botoc V, Vimeux S, Martino F, Giraudeau B, Reignier J; CRICS-TRIGGERSEP Group.
Targeted Temperature Management for Cardiac Arrest with Nonshockable Rhythm.
N Engl J Med. 2019 Oct 2. doi: 10.1056/NEJMoa1906661. [Epub ahead of print]
Keywords: e-cigarrette liquid exposure, National Poison Data System (PubMed Search)
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
Top 4 clinical/demographic characteristics are listed below.
Route of exposure
Level of care:
Clinical effects - overall
In <5 years group
Category: Critical Care
Blood Transfusion Thresholds in Specific Populations
Sepsis - 7 g/dL
Acute Coronary Syndrome - no current specific recommendations pending further studies
Stable Cardiovascular Disease - 8 g/dL
Acute Neurologic Injury - Traumatic Brain Injury - 7 g/dL
Postpartum Hemorrhage - 1:1:1 ratio strategy
Cable CA, Razavi SA, Roback JD, Murphy DJ. RBC Transfusion Strategies in the ICU: A Concise Review. Crit Care Med. 2019; epub ahead of print.
Keywords: Tenosynovitis, wrist pain (PubMed Search)
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
Keywords: ACEP, SAH, imaging, nonopioid, CTA, LP (PubMed Search)
Godwin SA, Cherkas DS, Panagos PD, et al. Clinical policy: critical issues in the evaluation and management of adult patients presenting to the emergency department with acute headache. Ann Emerg Med 2019;74(4):e41-74.
Follow me on Twitter @EM_NCC
Category: Critical Care
Keywords: VAPI, acute respiratory failure, vaping, e-cigarettes, e-hookah, juul, pulmonary disease, acute lung diease, ARDS (PubMed Search)
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 --
Treatment is supportive +/- steroids --
Bottom Line: Include vaping-associated pulmonary illness in your differential for patients presenting with acute lung disease.
Background: The use of electronic nicotine delivery systems, also known as e-cigarettes or vape pens, has risen precipitously since their introduction in 2006. They heat a liquid that can contain nicotine, THC/CBD, flavors and/or other additives, producing an aersol that is inhaled by users.
They have been marketed as a way to quit smoking, and as being safer than cigarettes. The U.S. is, however, currently experiencing an epidemic of a severe lung disesae termed Vaping-Associated Pulmonary Illness, with over 500 cases and 7 deaths across 38 states and 1 U.S. territory.
Per data obtained by the CDC:
CDC Emergency Preparedness & Response: "Severe Pulmonary Disease Associated with Using E-Cigarette Products" https://emergency.cdc.gov/han/han00421.asp
Keywords: Orthopedics, compartment syndrome (PubMed Search)
- 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.
Yue et al. Bilateral tibial tubercle avulsion fractures: Pediatric orthopedic injury at high risk for compartment syndrome. The American Journal of Emergency Medicine. Available online May 2019.
Keywords: capsaicin, cannabinoid hyperemesis syndrome, marijuna use. (PubMed Search)
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).
Wagner S et al. Efficacy and safety of topical capsaicin for cannabinoid hyperemesis syndrome in the emergency department. Clin Toxicol (Phila) 2019. Sep 4:1-5. doi: 10.1080/15563650.2019.1660783. [Epub ahead of print]
Category: Critical Care
Keywords: Pregnant, difficult airway (PubMed Search)
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.
Djabatey EA, Barclay PM. Difficult and failed intubationin 3430 obstetric general anesthesics. Anaesthesia 2009;64: 1168.
Izci B, Vennelle M, Liston WA, et al. Sleep-disordered breathing and upper airway size in pregnancy and post part. Our Respir J 2006; 27:321.
Lebowitz PW, Shay H, Straker T, et al. Shoulder and head elevation improves laryngoscope view for tracheal intubation in non obese as well as obese individuals. J Clin Anesth 2012; 24:104.
Keywords: foot fracture, radiology (PubMed Search)
Imaging of Lisfranc Injuries
3 Columns of the midfoot, divided by the tarsometatarsal 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
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.
On AP view:
On Lateral view:
On the Oblique view:
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
Keywords: UTIcalc, SBI, serious bacterial infection, febrile infant, urinary tract infection (PubMed Search)
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 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/
Shaikh N, Hoberman A, Hum SW, Alberty A, Muniz G, Kurs-Lasky M, Landsittel D, Shope T. Development and Validation of a Calculator for Estimating the Probability of Urinary Tract Infection in Young Febrile Children. JAMA Pediatr. 2018 Jun 1;172(6):550-556.
Keywords: ethanol, breath analyzer, mouth wash (PubMed Search)
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).
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
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)
Ernstgard L et al. Washout kinetics of ethanol from the airways following inhalation of ethnaol vapors and use of mouthwash. Clin Toxicol. 2019 Jun 19:1-7. doi: 10.1080/15563650.2019.1626868. [Epub ahead of print]
Category: Critical Care
Keywords: VAD, LVAD, Heart Failure (PubMed Search)
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.
Category: Pharmacology & Therapeutics
Keywords: droperidol (PubMed Search)
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.
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.
Perkins J, et al. American Academy of Emergency Medicine position statement: Safety of droperidol use in the emergency department. J Emerg Med. 2014;49(1): 91-97.
Keywords: nitrous oxide, neurotoxicity (PubMed Search)
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
Chronic toxicity causes myeloneuropathy (demyelination of the dorsal and lateral columns of the spinal cord) due to vitamin B12 deficiency
Category: Critical Care
Keywords: Atrial Fibrillation, sepsis, critical care, cardioversion, beta blockers, calcium channel blockers, rate control, rhythm control (PubMed Search)
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.
Bosch N, Cimini J, Walkey A. Atrial Fibrillation in the ICU. CHEST 2018; 154(6):1424-1434
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.
Paschos NK et al. Primary closure versus non-closure of dog bite wounds. A randomised controlled tira. Injury 2014 45(1): 23l7-40
Chen, HH et al. Analysis of Pediatric Facial Dog Bites. Cranomaxillofac Trauma Reconstr. 2013 Dec; 6(4):225-232
Ellis, R; Ellis, C (2014). "Dog and cat bites". American Family Physician. 90 (4): 239–43.