Category: Critical Care
Keywords: hyperoxia, oxygen therapy, saturation, SpO2, critical care, mechanical ventilation (PubMed Search)
Hyperoxia has been repeatedly demonstrated to be detrimental in a variety of patients, including those with myocardial infarction, cardiac arrest, stroke, traumatic brain injury, and requiring mechanical ventilation,1-4 and the data that hyperoxia is harmful continues to mount:
Bottom Line: Avoid hyperoxia in your ED patients, both relatively stable and critically ill. Remove or turn down supplemental O2 added by well-meaning pre-hospital providers and nurses, and wean down ventilator settings (often FiO2). A target SpO2 of >92% (>88% in COPD patients) or PaO2 >55-60 is reasonable in the majority of patients.8
Category: Pharmacology & Therapeutics
Keywords: naloxone, overdose (PubMed Search)
Providing naloxone to patients at risk for opioid overdose is now standard of care. A retrospective study evaluated the rate of naloxone obtainment after standardizing the process for prescribing naloxone in the emergency department and dispensing from the hospital outpatient pharmacy.
55 patients were prescribed naloxone. Demographics: mean age 48 years old, 75% male, 40% primary diagnosis of heroin diagnosis, 45.5% were prescribed other prescriptions.
Barriers identified included lack of ED dispensing program, cost of medication, even though cost is minimal and can be waived, and likely multifactorial reasons why patients did not present to pharmacy as instructed.
Take Home Points:
Verdier M, Routsolias JC, Aks SE. Naloxone prescriptions from the emergency department: An initiative in evolution. Am J Emerg Med. 2018;37(1)164-165.
Davies, P., and I. Maconochie. “The relationship between body temperature, heart rate and respiratory rate in children.” Emergency Medicine Journal 26.9 (2009): 641-643.
Daymont, Carrie, Christopher P. Bonafide, and Patrick W. Brady. “Heart Rates in Hospitalized Children by Age and Body Temperature.” Pediatrics 135.5 (2015): e1173-e1181.d
The National Institute for Health and Care Excellence. Pediatric Fever Guidelines, 2007 and 2013
Keywords: alcohol withdrawal syndrome, phenobarbital (PubMed Search)
Alcohol withdrawal syndrome is frequently treated with benzodiazepines following CIWA-Ar (Clinical Institute Withdrawal Assessment of Alcohol scale). There are other medications that are used as either second line or as adjunctive agents along with benzodiazepines. A retrospective study compared the clinical outcomes between phenobarbital vs. benzodiazepines-based CIWA-Ar protocol to treat AWS.
The primary was ICU length of stay (LOS); secondary outcome were hospital LOS, intubation, and use of adjunctive pharmacotherapy.
Study sample: 60 received phenobarbital and 60 received lorazepam per CIWA-Ar.
Adjunctive agent use
Phenobarbital therapy appears to be a promising alternative therapy for AWS. However, additional studies are needed prior to adapting phenobarbital as first line agent for AWS management.
Tidwell WP et al. Treatment of alcohol withdrawal syndrome: phenobarbital vs. CIWA-Ar protocol. Am J Crit Care. 2018 Nov;27(6):454-460. PMID: 30385536.
Keywords: diplopia, imaging, radiology, CT, ophthalmology (PubMed Search)
Diplopia can be a challenging complaint to address in the ED. Although not all patients will require imaging, use the simplified table below to help guide the imaging study needed:
Diplopia + cerebellar signs and symptoms
6th CN palsy + papilledema
Increased intracranial pressure (e.g. idiopathic intracranial hypertension or cerebral venous thrombosis)
3rd CN palsy (especially involving the pupil)
Compressive lesion (aneurysm of posterior communicating or internal carotid artery)
Diplopia + thyroid disease + decreased visual acuity
Optic nerve compression
Diplopia + facial or head trauma
Fracture causing CN disruption
CT head (dry)
Diplopia + multiple CN involvement (3,4,6) + numbness over V1 and V2 of trigeminal nerve (CN5) +/- proptosis
Unilateral, decreased visual acuity
Orbital apex pathology
CT orbits with contrast
Uni- or bi-lateral, normal visual acuity
Cavernous sinus thrombosis
C.N.: cranial nerve
Margolin E, Lam C. Approach to a Patient with Diplopia in the Emergency Department. 2018 Jun;54(6):799-806
Category: Critical Care
Keywords: resuscitation, liver failure, cirrhosis (PubMed Search)
A few (out of 10) tips for the care of sick patients with liver failure:
Fuhrmann V, Whitehouse T, Wendon J. The ten tips to manage critically ill patients with acute-on-chronic liver failure. Intensive Care Med. 2018;44(11):1932-5.
Keywords: Foreign bodies, coins, xrays (PubMed Search)
Coins are the most commonly ingested foreign body in the pediatric age group with a peak occurrence in children less than 5 years old. X-rays are considered the gold standard for definitive diagnosis and location of metallic foreign bodies. This study aimed to find a way to decrease radiation exposure by using a metal detector.
19 patients ages 10 months to 14 years with 20 esophageal coins were enrolled in the study. All proximal esophageal coins were detected by the metal detector. 5 patient's failed initial detection of the coin with the metal detector and all of those patients had the coin in the mid or distal esophagus with a depth greater than 7 cm from the skin.
Bottom line: A metal detector may detect proximal esophageal coins. This may have a role in decreasing repeat x-rays.
Aljasser A, Elmaraghy C and Jatana K. Utilization of a handheld metal detector protocol to reduce radiation exposure in pediatric patients with esophageal coins. International Journal of Pediatric Otolaryngology. 2018: 104-108.
Keywords: cervical, spine, clearance, triage, nurse, trauma (PubMed Search)
Bottom Line: ED triage nurses can safely use the Canadian C-Spine Rule. This approach can improve patient care and decrease length of stay in the ED.
Follow me on Twitter @EM_NCC
Category: Critical Care
Identifying Critically Ill Cancer Patients in the ED
Peyrony O, Shapiro NI. The 10 signs telling me that my cancer patient in the emergency department is at high risk of becoming critically ill. Intensive Care Med. 2018; epub ahead of print.
Keywords: head injury, sports medicine (PubMed Search)
In which age groups should children with Sport Related Concussion be managed differently from adults?
Are there targeted subgroups who would benefit from closer outpatient and specialty follow-up?
Predictors of Prolonged Recovery in Children
Davis et al., 2017. What is the difference in concussion management in children as compared with adults? A systematic review.
Zemek et al., 2016. Clinical Risk Score for Persistent Postconcussion Symptoms Among Children With Acute Concussion in the ED.
Keywords: PECARN, traumatic brain injury, head injury, concussion (PubMed Search)
Keywords: hydrocarbon ingestion, pediatric poisoning (PubMed Search)
The management of pediatric hydrocarbon ingestion has not changed significantly over the past several decades. One of the earlier study that helped established the management approach is by Anas N et al. published in JAMA, 1981.
It was a retrospective study of 950 children who ingested household hydrocarbon containing products.
Discharged patients: n=800
Admitted patients: n=150
This study recommended that hospitalization is required in patients…
Anas N. et al. Criteria for hospitalizing children who have ingeted products containing hydrocarbons. JAMA 1981;246:840-843
Category: Critical Care
Keywords: resuscitation, cardiac arrest, post-cardiac arrest care, blood pressure, MAP, ROSC (PubMed Search)
The most recent AHA guidelines for goal blood pressure after return of spontaneous circulation (ROSC) post-cardiac arrest recommend a definite mean arterial pressure (MAP) goal of > 65 mmHg.1 There is no definitive data to recommend a higher specific goal, but there is some evidence to indicate that maintaining higher MAPs may be associated with better neurologic outcomes.2
A recently published prospective, observational, multicenter cohort study looked at neurologic outcomes corresponding to different MAPs maintained in the initial 6 hours post-cardiac arrest.3
1. Compared to lower blood pressures (MAPs 70-90 mmHg), the cohort with MAPs > 90 mmHg had:
2. The association between MAP > 90 mmHg and good neurologic outcome was stronger among patients with a previous diagnosis of hypertension, and persisted regardless of initial rhythm, use of vasopressors, or whether the cardiac arrest occured in or out of hospital.
3. There was a dose-response increase in probability of good neurologic outcome among all MAP ranges above 90 mmHg, with MAP >110 mmHg having the strongest association with good neurologic outcome at hospital discharge.
Note: The results of a separate trial, the Neuroprotect post-CA trial, comparing MAPs 85-100 mmHg to the currently recommended MAP goal of >65 mmHg, are pending.4
Bottom Line: As per current AHA guidelines, actively avoid hypotension, and consider use of vasopressor if needed to maintain MAPs > 90 mmHg in your comatose patients post-cardiac arrest, especially those with a preexisting diagnosis of hypertension.
Category: Pharmacology & Therapeutics
Keywords: Intranasal Administration, Alternative Administration (PubMed Search)
The most common methods of medication administration in the emergency department are oral, intravenous (IV), and intramuscular (IM). If the oral route is not available, if IV/IM are not necessary, or if obtaining IV access is challenging, intranasal (IN) medication delivery is a reasonable alternative. More concentrated products are preferred and a volume of 1 mL or less per nostril should be utilized. Below is a table of the commonly used medications used via the IN route.
|Drug||Concentration||Indication||IN Dose|| |
Time to Peak Effect
|Fentanyl||50 mcg/mL||Analgesia||0.5-2 mcg/kg||5 min|| |
Nasal irritation, rhinitis, headache
|Ketamine||100 mg/mL|| |
Analgesia, Agitation, Sedation
|3-6 mg/kg||5-10 min|| |
Poor taste, HTN, hypersalivation, agitation, emergence reaction
|Lorazepam||2 mg/mL|| |
Max: 4 mg
|30 min|| |
Poor taste, lacrimation, nasal/throat irritation
|Midazolam||5 mg/mL|| |
Agitation, Sedation, Seizures
Max: 10 mg
|5-10 min||Same as lorazepam|
|Naloxone||1 mg/mL|| |
|1-5 min|| |
N/V, headache, withdrawal symptoms
Bailey AM, Baum RA, Horn K, et al. Review of intranasally administered medications for use in the emergency department. J Emerg Med. 2017;53:38-48.
Keywords: head injury (PubMed Search)
Concussion Management in Children
What are the predictors of prolonged recovery of concussion in children?
Female sex, age greater than 13, prior physician diagnosis of migraine, prior concussion with symptoms lasting longer than 1 week, history of multiple concussions, headache, sensitivity to noise, dizziness, fatigue, answering questions slowly and four or more errors on tandem stance testing.
Age: As compared to younger children, adolescents have a greater number of and more severe postconcussive symptoms. They take longer to recover and return to school and sport.
Subjects: Math tends to pose greater problems followed by reading/language, arts, sciences and social studies.
Computer testing: The widespread use of computer neuropsychological testing is not recommended in children and adolescents. This is due to issues with reliability over time and insufficient evidence of both diagnostic and prognostic value. When used, reference to normative data should be done with caution. Testing should also NOT be used in isolation in concussion diagnosis and management.
Davis et al., 2017. Br J Sports Med 2017.
Keywords: CSF, lumbar puncture, infectious diseases (PubMed Search)
Manifestations due to neurosyphilis present as one of 3 categories: stroke due to arteritis, masses in the brain (granulomata), and chronic meningitis.
Although serum VDRL/TPPA tests will be positive in almost all patients, it’s important to remember that the diagnosis requires the presence of ALL of the following criteria:
1. positive treponemal (e.g. FTA-ABS, TP-PA) AND nontreponemal (e.g. VDRL, RPR) serum test results
2. positive CSF VDRL OR positive CSF FTA-ABS test result
3. one CSF laboratory test abnormality, such as pleocytosis (cell count >20/μL) or high protein level (>0.5 g/L)
4. clinical symptoms
This is important because the treatment of neurosyphilis is distinctly different from other forms, as it requires admission for IV antibiotics for at least 10 days.
Bonus Pearl: CSF RPR is unreliable as it is more likely to be falsely positive than other specific CSF testing.
Halperin JJ. Neuroborreliosis and Neurosyphilis. CONTINUUM 2018;24(5):1439–1458
Keywords: C-Spine Clearance, altered mental status (PubMed Search)
Keywords: Infection, fever, blood work, CRP (PubMed Search)
Historically, the C-reactive protein (CRP) has been used in the assessment of the febrile child and is the only biomarker recommended by the National Institute for Health and Care Excellence (NICE).
CRP increases 4-6 hours after the onset of inflammation, doubling every 8 hours and peaking at 36-50 hours. It rapidly decreases once the inflammation has resolved.
An elevated CRP alone is not conclusive of a serious bacterial infection (SBI).
A CRP >75 mg/L increased the relative risk of SBI by 5.4.
A CRP <20 mg/L decreased the risk of SBI, but there was still a small subset of children where SBI was present.
In infants < 3 months initial CRP measurements are poorly accurate, but when trended may be useful in deciding when to stop antibiotics (rather then when to start them). A normalizing CRP demonstrated a 100% negative predictive value for excluding invasive bacterial infection.
CRP is not a rule in/rule out test
CRP is not helpful in diagnosing SBI, but serial measurements may be useful in monitoring response to treatment
CRP has a limited role in well appearing children older than 3 months
Dyer EM, Waterfield T, Baynes H. How to use C-reactive protein. Arch Dis Child Educ Pract Ed 2018; 0:1-4.
Keywords: Hyperemesis, Cannabinoid (PubMed Search)
Bottom line: Patient education should be provided on the paradoxical and recurrent nature of the symptoms of CHS to discourage relapse of use often stemming from false preception of beneficial effects of cannabis on nausea.
Cannabinoid hyperemesis: a case series of 98 patients. Simonetto DA, Oxentenko AS, et al,Mayo Clin Proc. 2012;87(2):114–9
Cannabinoid hyperemesis syndrome: potential mechanisms for the benfit of capsaicin and hot water hydrotherapy in treatment. Richards JR, Lapoint JM, et al. Clin Tox(phila) 2018 Jan :56(1): 15-24.
Cannabinoid Hyperemesis Syndrome: Public Health Implications and Novel Model Treatment Guidelines. West J Emerg Med. 2018 Mar:19(2):380-386.
Keywords: Concussion, return to play, school, head injury (PubMed Search)
You have successfully diagnosed a concussion, explained everything to the parents, closed the encounter, reached for the doorknob and….
“What about school?”
An athlete should not return to play until they have successfully returned to school
Several studies have demonstrated that intense cognitive stimulation and intense intellectual stimulation result in worsening symptoms
-school work, TV, videogames, texting
Attempt to limit cognitive activity to the point where it begins to reproduce or worsen symptoms!
Step 1: 24 to 48 hours of rest
Step 2: Daily at home activities that do not increase symptoms. Starting with 5 – 10 minutes and gradually build up to a goal of tolerating 30 minutes of cognitive activity without worsening symptoms.
Home work, reading assignments, other cognitive activities
Step 3: Attempt Return to school (will not be completely symptoms free!) with either part time, partial days, or with extended breaks. Goal of tolerating an entire school day without symptoms.
Most students recover fully within 4 weeks and adjustments can then be discontinued. Others with ongoing symptoms may require ongoing academic modifications (extra time for tests, papers, etc).
Suggested examples of adjustments: Shortened days, 15 minute break for every 30 minutes of instruction, providing class notes, tutoring, decreasing course expectations, decreasing exposure to classes which exacerbate symptoms, no computer work, untimed tests and quizzes, lunch in a quiet place.
Bass & Valasek Auguest 2018 Contemporary Pediatrics