This was a database study of nearly 2 million trauma patients over age 65 who were discharged looking at all levels of trauma centers. The authors found:
“Dominance analysis showed that proportion of patients with Injury Severity Score of >15 contributed most to explaining hospice utilization rates (3.2%) followed by trauma center level (2.3%), proportion White(1.9%), proportion female (1.5%), and urban/rural setting (1.4%).”
Level one centers had the lowest level of discharge to hospice. The authors felt: “As the population ages, accurate assessment of geriatric trauma outcomes becomes more critical. Further studies are needed to evaluate the optimal utilization of hospice in end-of-life decision making for geriatric trauma.”
This study is out of the American University of Beirut, Lebanon, and courtesy of our own Mazen El Sayed!
Many patients of Muslim faith will observe fasting during the month of Ramadan, with no food, water, oral of IV medication taken from sunrise to sunset
This study showed a lower daily ED volume than during non Ramadan months, however did show a higher length of stay during Ramadan.
It also found an increase in mortality rates during Ramadan (OR 2.88) and 72 hour ED bounce-backs (OR 1.34)
Be sensitive and aware of the needs of your patients of Muslim faith during this holy month of fasting.
Ramadan Kareem
The gold standard for confirming ETT position is a chest xray, but this can often be delayed while the patient is stabilized. Many physicians will estimate ETT insertion depth to be 3x the ETT size, but this is based on selection of the correct tube. There are several other published formulas, including the PALS guidelines [age in years/2 + 12] which applies to children older than one year. In 1982, there was an article published that cited the formulas of [Height (cm) x 0.1 +5] or [Weight(kg)/5 + 12].
This was a retrospective study where the ideal position of cuffed ETT (from the front teeth) was determined by looking at post intubation xrays of 167 patients between 28 days and 18 years. The individual optimal ETT insertion depth was plotted against age, weight and height for all children. This study showed that there is not a fully linear relationship between age, height or weight which is a flaw of all of these formulas. Calculations using the patients’ weight performed the worst. Age based and height formulas performed the best.
MYTH: Bactrim cannot be used as monotherapy for nonpurulent skin and soft tissue infections.
Not True!
Organisms of concern: Streptococcus spp.
Here’s why:
TRUTH: Bactrim CAN be used as monotherapy for nonpurulent skin and soft tissue infections.
Prepared by Rianna Fedora, PharmD on 2/26/24
Background: There is no clear guidelines regarding whether norepinephrine or epinephrine would be the preferred agent to maintain hemodynamic stability after cardiac arrest. In recent years, there has been more opinions about the use of norepinephrine in this situation.
Settings: retrospective multi-site cohort study of adult patients who presented to emergency departments at Mayo Clinic hospitals in Minnesota, Florida, Arizona with out-of-hospital-cardiac arrest (OHCA). Study period was May 5th, 2018, to January 31st, 2022
Participants: 18 years of age and older
Outcome measurement: tachycardia, rate of re-arrest during hospitalization, in-hospital mortality.
Multivariate logistic regressions were performed.
Study Results:
Discussion:
It was retrospective study that uses electronic health records. Thus, other important factors from the pre-hospital settings might not be accurate.
On the other hand, the patient population came from multiple hospitals with varying practices so the patient population is more generalizable.
Conclusion:
Although the rate of tachyarrhythmia was not different between patients receiving norepinephrine vs. epinephrine after ROSC. This study would add more data to the current literature that norepinephrine might be more beneficial for patients with post-cardiac arrest shock.
What happens if you have a patient who steps on a nail? How can you make this procedure easier for you and the patient?
– Use a Posterior Tibial Nerve Block! !
To Perform This Procedure:
This secondary analysis of the NEXUS head injury data found patients over 65:
-sustained more significant injuries than younger pts
-presented more frequently with occult injuries
-when they required neurosurgery intervention only 16% went home, 32% were discharged to rehab facility and 41% died
-mechanism of injury was most commonly fall from standing
-mortality rates were highest for fall from ladder and auto vs. pedestrian injuries
The authors concluded: “Older blunt head injury patients are at high risk of sustaining serious intracranial injuries even with low-risk mechanisms of injury, such as ground-level falls. Clinical evaluation is unreliable and frequently fails to identify patients with significant injuries. Outcomes, particularly after intervention, can be poor, with high rates of long-term disability and mortality.”
Acetaminophen and low back pain.
Acetaminophen has been a traditionally recommended first line intervention for acute low back pain.
Cochrane reviews in 2016 and 2023 found that acetaminophen showed no benefit compared to placebo in patients with acute low back pain.
A 2020 study investigated whether the addition of acetaminophen to short term NSAID therapy was beneficial.
A randomized double-blind study conducted in two urban emergency departments.
Patients randomized to a 1-week course of ibuprofen plus acetaminophen versus ibuprofen plus placebo.
Population: patients presenting with acute, non-radicular, non-traumatic lower back pain of fewer than two weeks duration.
Authors compared pain and functional outcomes at one week following discharge.
Conclusion: there was no outcome benefit from the addition of acetaminophen to ibuprofen.
This is a retrospective study looking at traumatic brain injury patients comparing those with and without pre-existing psychiatric illness at the time of injury. Those with pre-existing illness had longer hospital stays, longer ICU stays and more frequent readmissions.
This classic article should be on everyone’s reading list.
The Bottom Line: Clinicians engaging in metacognition, that is thinking about our reasoning process, can avoid making some critical errors and falling victim to cognitive biases.
Diagnostic errors are common in clinical medicine and particularly common in situations in which the clinician is faced with a novel circumstance and cannot, therefore easily apply heuristics or rules. There are also certain classic situations in which cognitive errors often occur (e.g., mistaking intracranial injury for intoxication). Through a process of active consideration of one’s diagnostic approach, many errors and cognitive biases (particularly availability bias and anchoring bias) can be avoided.
Take-home message: This article is worth reading in its entirety. Applying these principles can protect both patients and clinicians from the consequences of diagnostic errors.
You've heard of one kill pills such as calcium channel blockers, beta blockers, sulfonylureas, anti-malarials, but less commonly known is benzonatate, or tessalon perles.
Tessalon perles are not recommended for children under the age of 10. 1-2 capsules of benzonatate in children <2 years old have been reported to cause serious side effects including restlessness, tremors, convulsions, coma and even cardiac arrest rapidly after ingestion (within 15-20 minutes and death within a couple of hours). It is attractive to young children as it somewhat resembles a jelly bean.
Pearls on Tessalon Perles:
This meta analysis did not find convincing evidence for or against seizure prophylaxis for admitted moderate to severe traumatic brain injury pts. They recommend Levetiracetam over other medications again on weak evidence.
The relationship between an Emergency Physician and the hiring group (whether large or small) may be one of employer-employee or contactor-independent contractor. There are legal job protections for employees that don’t exist for independent contractors. There are also regulations that define an independent contractor. Enforcement of these regulations varies but may be increasing. This has implications for the Emergency Medicine job market. We have the highest percentage of independent contractors of any medical specialty.
See more at Leon Adelman’s Emergency Medicine Workforce Newsletter, here https://emworkforce.substack.com/p/thousands-of-employed-emergency-physicians
Evidence is mounting that individuals with active or past history of cancer are at increased risk for acute cardiovascular events such as as acute myocardial infarction. This secondary analysis from the APACE (Advantageous Predictors of Acute Coronary Syndromes Evaluation) study- a multicenter, international, prospective diagnostic study looked at the prevalence of MI in patients with history of cancer presenting to the ED with acute chest pain, diagnostic accuracy of high-sensitivity troponins and diagnostic algorithms (European Society of Cardiology algorithm- see paper for details), among a few other parameters.
Take home points:
Translation to practice:
Be more conservative with cancer patients presenting to the ED with acute chest pain!
In this study, geriatric hip fracture patients with a hemoglobin less than 7.1 had higher mortality, especially in those over age 79, even when controlling for other factors such as ASA Physical status class, anti-platelet use, etc.
Axial neck pain is a dull aching “soreness” pain from the posterior neck muscles with radiation to the occiput, periscapular and shoulder regions.
Associated with headaches, stiffness and muscle spasm.
Patients with cervical radiculopathy, however, usually present with unilateral pain discomfort.
Patients may complain of pain radiation into the ipsilateral arm. Though frequently difficult to describe, this may be in a dermatomal distribution. Patients may also report decreased sensation in a dermatomal distribution or weakness along the corresponding myotome.
The most affected nerve roots are C7 (C6-7 herniation), followed by C6 (C5-6 herniation) and C8 (C7-T1 herniation).
Cervical Spondylosis (degenerative change) is the most common ideology.
As discs breakdown with age and lose height, increased force loads are transmitted to bony regions of the spinal segment leading to bone hypertrophy which creates foraminal stenosis and resultant radiculopathy.
Cervical radiculopathy, like lumbar radiculopathy, is largely a self-limited condition. Several older studies following this diagnosis revealed that a majority of patients were either asymptomatic or mildly symptomatic at time of follow-up.
Improvement is seen over the initial four to six months following diagnosis.
This research letter notes: “The Rural Emergency Hospital is a new Medicare payment model available to hospitals with 50 or fewer beds in rural areas. Rural hospitals converting to this model will have emergency department (ED), observation, and outpatient services.”. Their study concludes that the majority of these hospitals already transfer the vast majority of their admissions to larger hospitals and this designation is a recognition of already established practices.
Vital signs in children can be difficult to remember since they vary with age. Using a standardized card or app (such as PALS) can help EMS clinicians remember the values. Most pediatric vital sign reference ranges were derived from samples of healthy children in the outpatient setting (ie PALS). This study attempted to validate a range of pediatric vital signs that were more accurate in predicting the need for prehospital interventions compared to the standard PALS vital sign ranges. The thought was that by using EMS data, these vital sign ranges could better alert EMS to patients in need of acute intervention.
The authors used a large EMS database to determine the vital signs for the patients age and correlated that to prehospital interventions (including IV, medication, EKG, advanced airway management, ect). They used the <10% and >90% for the age values (termed "extreme" vitals signs) as a cut off to be considered abnormal. Using the EMS derived values, 17.8% of the encounters with an extreme vital sign received medication. If the PALS abnormal vital sign range was used, only 15.2% of those patients were given medications. Overall, encounters with an extreme vital sign had a higher proportion of any intervention being performed compared to other vital sign criteria (i.e. only 33.7% with PALS).
These extreme vital signs also had a greater accuracy in predicting mortality.
Bottom line: While vital signs are based on physiology that does not change based on location, using a seperate criteria for the EMS population, can improve discrimination between sick and sicker patients and hopefully allow EMS to recognize and intervene on sicker patients sooner.
Background: Acutely intoxicated / poisoned patients are commonly encountered in the ED, with the classic teaching that a GCS < 9 is an indication to intubate for airway protection. But we’ve probably all had a patient who was borderline, or who we thought was still protecting their airway pretty well despite a lower GCS. Are we risking our patient’s health and our careers by holding off on intubation? Maybe not.
The NICO trial, a multicenter, randomized controlled trial, looked at patients presenting by EMS with GCS <9 due to suspected poisoning, without immediate indication for intubation (defined by signs of respiratory distress with hypoxia, clinical suspicion of any brain injury, seizure, or shock with systolic BP <90 mmHg). They found that withholding intubation with close monitoring, compared to the standard practice of intubating at the EMS or ED physician’s discretion, resulted in:
Comparing the patients who were intubated in each group, there was no significant difference between groups in:
Notes:
Bottom Line: Without clear indication for intubation such as respiratory distress or accompanying head bleed, etcetera, intubation for mental status alone shouldn't be dogma in acute intoxication. Close monitoring will identify need for intubation, without apparent worsened outcomes due to a watchful waiting approach.
This retrospective study of 66 trauma patients who had pelvic fractures attempted to determine if prehospital applied pelvic binders had an impact on mortality. There were 3 cohorts: appropriately applied binders (14), inappropriately applied (14 not at the level of the greater trochanter), and none applied (38). Survival for applied was 92% and those without was 81% which was not statistically significant. The authors concluded: “In conclusion, our study found that the use of prehospital pelvic binders did not show a significant effect on patient outcomes for those with unstable pelvic fractures. Instead, injury severity score (ISS) emerged as the most significant predictor of survival.”
Previous studies have shown regular education is needed on proper use of binders. We should continue to educate on appropriate positioning and the use of pelvic binders. For me, this study is not large enough to convince that we should go away from binder use. We need more data before we abandon the pelvic binder.
