Keywords: Measles, outbreak, complications (PubMed Search)
Measles outbreaks have been reported all over the globe, with the incidence increasing due to low immunization rates. Italy experienced 5000 cases in 2017. This study was a retrospective multicenter observational study of children less than 18 years hospitalized for clinically and laboratory confirmed measles over a year and a half period from 2016-2017.
There were 263 cases of measles that required hospitalization during this time and 82% developed a complication with 7% having a severe clinical outcome defined by a permanent organ damage need for ICU care or death. A CRP value of greater than 2 mg/dL was associated with a 2-4 fold increased risk of developing complications. 23% developed pneumonia and 9.6% developed respiratory failure. Hematologic involvement was seen in 48% of patients. 1.2% of hospitalized patients died.
Bottom line: Consider CRP, lipase and CBC at a minimum in your patients with suspected measles who require hospitalization.
Lo Vecchio A, Krzysztofiak A,
Keywords: laundry pod exposure, toxicity (PubMed Search)
Single use laundry pods are readily available in many homes. Due to their bright colors, they have been mistaken for edible products (e.g. candy) by children.
A recent study reviewed 4652 laundry pod exposures from United Kingdom.
95.4% involved children aged < 5 years via oral route (89.7%).
Common symptoms in moderate/severe symptom groups, including fatality (n=127)
Day R, Bradberry SM, Jackson G, et al. A review of 4652 exposures to liquid laundry detergent capsules reported to the United Kigndom National Poisons Information Service 2008 - 2018. Clin Toxicol (Phila). 2019 Mar 20:1-8. doi: 10.1080/15563650.2019.1590586. [Epub ahead of print]
Category: Critical Care
Mechanical Ventilation in the Obese Critically Ill
Schetz M, et al. Obesity in the critically ill: a narrative review. Intensive Care Med. 2019 [epub ahead of print].
Keywords: CT, head, radiation (PubMed Search)
Most (65%) scans were performed at nonacademic adult centers
Strauss et al., 2019. Radiation Dose for Pediatric CTT: Comparison of Pediatric versus Adult Imaging Facilities
Keywords: closed head injury, concussion, CHI (PubMed Search)
Over 630,000 children visit the ED every year with a diagnosis of concussion
Predictors of persistent post-concussive symptoms (PPCS):
Appromixately 1/3 of pediatric patients will have PPCS lasting over 2 weeks
Likelihood of PPCS increases to >50% in those with risk factors identified in the ED
Every state has a youth concussion law. The basic tenants are a) immediate removal from play b) written clearance from health professional to return to play c) education for athlete, parents, coaches.
Keywords: 23.4%, mannitol, intracranial hypertension, herniation, IO (PubMed Search)
Bottom Line: Use of IO allows more rapid administration of 23.4% NaCl with no immediate serious complications.
Wang J, Fang Y, Ramesh S, et al. Intraosseous administration of 23.4% NaCl for treatment of intracranial hypertension. Neurocrit Care. 2019;30(2):364-371.
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Category: Critical Care
Keywords: Resuscitation, cardiac arrest, POCUS, ultrasound, ROSC (PubMed Search)
Background: Previous systematic reviews1,2,3 have indicated that the absence of cardiac activity on point-of-care ultrasound (POCUS) during cardiac arrest confers a low likelihood of return of spontaneous circulation (ROSC), but included heterogenous populations (both traumatic and atraumatic cardiac arrest, shockable and nonshockable rhythms).
The SHoC investigators4 are the first to publish their review of nontraumatic cardiac arrests with nonshockable rhythms, evaluating POCUS as predictor of ROSC, survival to admission (SHA), and survival to discharge (SHD) in cardiac arrests occurring out-of-hospital or in the ED.
Bottom Line: In nontraumatic cardiac arrest with non-shockable rhythms, the absence of cardiac activity on POCUS may not, on its own, be as strong an indicator of poor outcome as previously thought.
Keywords: discharge planning, elderly (PubMed Search)
Elderly patients (mean age of 84 years) living in the community who are seen and discharged from the Emergency Department due to illness or injury are at increased risk for further disability and functional decline for at least six months after their visit. This is associated with increased mortality, cost and need for long term care in previously self-functioning individuals. * When appropriate to discharge from the ED, we should consider discharge planning that includes coordination with care management services to be sure these individuals have adequate home support systems in place and access to close outpatient follow-up.
*It should be noted that the risk is even greater after inpatient hospitalization.
Nagurney, Justine M. et al., Emergency Department Visits Without Hospitalization Are Associated With Functional Decline inOlder Persons, Annals of Emergency Medicine, 2016; 69(4): 426 – 433. doi.org/10.1016/j.annemergmed.2016.09.018.
Category: Pharmacology & Therapeutics
Keywords: Serotonin Syndrome, SHIVERS (PubMed Search)
Identifying serotonin syndrome in the emergency department can be difficult without an accurate patient history. Furthermore, the physical symptoms may look similar to many other disorders such as neuroleptic malignant syndrome and anticholinergic toxicity. If you remember the acronym SHIVERS, you can easily recognize the signs and symptoms of serotonin syndrome.
Shivering: Neuromuscular symptom that is unique to serotonin syndrome
Hyperreflexia and Myoclonus: Seen in mild to moderate cases. Most prominent in the lower extremities. This can help differentiate from neuroleptic malignant syndrome which would present with lead-pipe rigidity.
Increased Temperature: Not always present, but usually observed in more severe cases
Vital Sign Abnormalities: Tachycardia, tachypnea, and labile blood pressure
Encephalopathy: Mental status changes such as agitation, delirium, and confusion
Restlessness: Common due to excess serotonin activity
Sweating: Autonomic response to excess serotonin. This symptom can help differentiate from anticholinergic toxicity in which the patients would present with increased temperature but dry to the touch
Once serotonin syndrome is identified, it is important to discontinue all serotonergic agents, provide supportive care with fluids, and sedate with benzodiazepines. Sedation with benzodiazepines helps to decrease myoclonic jerks which also helps with temperature control. If patients are hyperthermic, they will require intensive cooling. Cyproheptadine, a potent antihistamine and serotonin antagonist, should also be administered. The initial dose of cyproheptadine in serotonin syndrome is 12mg which can be followed by 2 mg every 2 hours as needed for symptom control.
2. Ables AZ, Nagubilli R. Prevention, Recognition, and Management of Serotonin Syndrome. AFP. 2010;81(9):1139-1142.
Keywords: lipid emulsion therapy (PubMed Search)
Intravenous lipid emulsion (ILE) is use as a therapy of last resort in refractory cardiovascular shock from toxicity of select agents (e.g. calcium channel blockers, beta blockers and select Na-channel blocking agents). There are number of case reports/series that showed positive cardiovascular/hemodynamic response after ILE, which are prone to publication bias. Results from limited number of human trials have shown mixed results.
A study reviewed fatal cases of poisoning that received ILE from the National Poison Data System to characterize the clinical response of ILE therapy.
N=459 cases from 2010 to 2015.
Most common substance involved
Number with ROSC (%)
Local anesthetics – parenteral*
*Use of ILE supported by Lipid work group
Possible adverse reactions (n)
Category: Critical Care
The Lung Transplant Patient in Your ED
Welte T, et al. Ten tips for the intensive care management of transplanted lung patients. Intensive Care Med. 2019; 45:371-3.
Hospitalization for Suicide Ideation or Attempt: 2008-2015. Pediatrics. Pelmons. 2018
Special Considerations in the Pediatric Psychiatric Population. Psychiatric Clinics. Santillanes 2017.
Sarah Edwards, DO. Medical & Program Director. Child and Adolescent Psychiatry. University of Maryland School of Medicine.
Keywords: Scromboid, Histamine (PubMed Search)
Scromboid (histamine fish poisoning) can be easily misdiagnosed since its' clinical presentation can mimic that of allergy. Seen most frequently in the summer and occurring with Scombroideafish (tuna, mackerel, bonito, skipjack) but also with large dark meat fish (sardines and anchovies) and even more commonly with nonscromboid fish such as mahi mahi and amber jack. In warm conditions when fish is improperly refrigerated, bacterial histidine decarboxylase converts muscle histidine into histamine which quickly accumulates. Histamine is heat stable and not destroyed with cooking.
Scromboid poisoning is due to histamine ingestion and is often misdiagnosed as allergic reaction. It is preventable with proper fish storage.
Severe scombroid fish poisoning: an underrecognized dermatologic emergency. Jantschitsch C, Kinaciyan T, et al. J Am Acad Dermatol 2011; 65:246–7.
Histamine fish poisoning: a common but frequently misdiagnosed condition. Attaran RR, Probst F. Emerg Med J 2002;19:474–5.
Category: Critical Care
Keywords: heart transplant, arrhythmias, critical care (PubMed Search)
When managing transplant patients it is important to keep in mind the anatomic and physiologic changes that occur with the complete extraction of one person's body part to replace another's.
For cardiac transplant patients with symptomatic bradycardia:
For cardiac transplant patients with tachyarrythmias:
Stecker EC, Strelich KR, Chugh SS, et al. Arrythmias after orthotopic heart transplantation. J Card Fail. 2005;11(6):464-72.
Thajudeen A, Stecker EC, Shehata M, et al. Arrhythmias after heart transplantation: Mechanisms and management. J Am Heart Assoc. 2012;1(2):e001461.
Category: Critical Care
Hyponatremia in the Brain Injured Patient
Mrozek S, et al. Pharmacotherapy of sodium disorders in neurocritical care. Curr Opin Crit Care. 2019; 25:132-7.
Keywords: Spine infection, back pain (PubMed Search)
Laboratory testing for Spinal Epidural Abscess
The CBC is poorly sensitive/specific
The WBC count may be nml or elevated
Left shift and bandemia may or may not be present
ESR and CRP
Sensitive but not specific
Elevated in >80% with vertebral osteomyelitis.
Reihsaus E, et al. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 2000.
Keywords: headache, back pain, misdiagnosis, stroke, intraspinal, epidural, abscess (PubMed Search)
Bottom Line: The rate of serious neurologic conditions missed at an initial ED visit is low. However, the potential harm of misdiagnosis can be substantial.
Keywords: kratom, adverse effects, poison center data (PubMed Search)
Kratom (Mitragyna speciosa) has been used for centuries in Southeast Asia to manage pain and opium withdrawal. It is increasingly being used in the U.S. for similar purpose. The U.S. DEA lists Kratom as a “drug of concern”.
Effects of Kratom leaves
A study reviewed National Poison Data System (2011 to 2017) to evaluate the clinical effects/outcomes of Kratom exposure.
Finding: (N=1807; single-substance: 1174; multiple-substance: 633])
Sara Post, Henry A. Spiller, Thitphalak Chounthirath & Gary A. Smith (2019): Kratom exposures reported to United States poison control centers: 2011–2017, Clinical Toxicology, DOI: 10.1080/15563650.2019.1569236
Category: Critical Care
Keywords: Airway management, acute respiratory failure, hypoxia, intubation, preoxygenation (PubMed Search)
The PROTRACH study recently compared preoxygenation with standard bag valve mask (BVM) at 15 lpm to preoxygenation + apneic oxygenation with high flow nasal cannula 60 lpm/100% FiO2 in patients undergoing rapid sequence intubation.
Guitton C, Ehrmann S, Volteau C, et al. Nasal high-flow preoxygenation for endotracheal intubation in the critically ill patient: a randomized clinical trial. Intensive Care Med. 2019. doi: 10.1007/s00134-019-05529-w. [Epub ahead of print]
Keywords: back pain, back emergency (PubMed Search)
Cauda Equina Syndrome (CES)
A recent pearl discussed CES. This is a very challenging diagnosis to make, especially on initial presentation
The 5 “classic” characteristic features are
Not all symptoms will be present in a given patient and there is no sign/symptom combination that either reliably diagnoses or excludes CES.
To illustrate how difficult this diagnosis is to make, a study looked at the predictive abilities of Neurosurgical residents.
Positive MRI for CES was accurately predicted by senior neurosurgical residents in approximately 50% of patients suspected of CES based on history and physical findings. As clinical certainty only becomes apparent with the classic symptoms (which are generally late findings) waiting to initiate MRI will delay decompressive surgery and can lead to worsened functional outcomes. This leads to increased MRI demand with more negative MRIs. Not surprisingly, only ~20% of MRI scans for suspected CES are positive.
Bell DA et al. Cauda equina syndrome: what is the correlation between clinical assessment and MRI scanning? Br J Neurosurg 2007;21:201-3.