Lactate is commonly used in the adult ED when evaluating septic patients, but there is a lack of literature validating its use in the pediatric ED. Pediatric studies have suggested that in the ICU population, elevated lactate is a predictor of mortality and may be the earliest marker of death.
A retrospective chart review over a 1 year period showed that one elevated serum lactate correlated with increased pulse, respiratory rate, white blood cell count and platelets. Serum lactate had a negative correlation with BUN, serum bicarbinate and age. Elevated lactate levels were higher for admitted patients. However, the mean serum lacate level was not statistically different between those diagnosed with sepsis and those that were not.
The study included 289 patients less then 18 years who had both blood cultures and lactate drawn. This community hospital had a sepsis protocol in place that automatically ordered a lactate with blood cultures. Only previously healthy children were included.
The study is limited by its small sample size and overall low lactate levels. Despite having a protocol in place, only 39% of patients who had blood cultures drawn had lactate levels available for analysis. The mean serum lacate in this study was 2.04 mM indicating that the study population may not have been sick enough to determine mortality implications. There were no serial measurements.
Bottom line: Consider measuring serum lacate in your pediatric patient with suspected sepsis. Pediatric ICU literature does suggest that an serum lactate as low as 3mM is associated with an increased mortality in the ICU.
The internet has become a wealth of information and some books have now gained internet noteriety. A chemist and author of the book - TIKHAL: Tryptamines I Have Known and Loved is an excellent example.
Tryptamines include drugs like LSD and alpha-methyltryptamine (AMT). Vivid visual hallucinations and serotonin agonism, these drugs were glamorized by this author. He would synthesize a tryptamine and then "taste it". Take a look at the link below where he first describes the biochemical synthesis he performed then describes his dose response effect when he tried the drug.
If you run into a drug or slang term in the ED you are not familiar with, the website www.erowid.org will likely have the translation.
http://www.erowid.org/library/books_online/tihkal/tihkal48.shtml
COPD treatment guidelines (e.g., GOLD) recommend 10-14 days of steroid therapy following a COPD exacerbation to prevent recurrences; the supporting data is weak.
A recent noninferiority trial (here) compared patients with a severe COPD exacerbation who received either a 5-day course (n=156) or 14-day course (n=155) of prednisone 40mg.
The results were:
What you need to know:
Bottom-line: 5 days of prednisone may be as effective as 14-days for COPD exacerbations.
46 year-old female presents with a headache. The following is seen on visual inspection of the eye. What's the diagnosis?
Radiation therapy is frequently utilized in the management of numerous thoracic malignancies
Cardiovascular disease is now the leading cause of nonmalignancy death in radiation-treated cancer survivors
The spectrum of radiation-induced cardiac disease is broad
The relative risk of CAD, CHF, pericardial/valvular disease, and conduction abnormalities is particularly increased
Early identification of potential cardiac complications w/cardiac MR and echocardiography provides an opportunity for regular assessment and potentially improved long term mortality
Tests for distal ulnar nerve entrapment
Ask patient to hold a piece of paper between the thumb and the index finger
Normally this is a fairly simple task.
With an unlar nerve palsy, the patient will substitute with the FPL (flexor pollicis longus - median nerve innervation). This causes flexion of the thumb in order to maintain the grip since the adductor pollicis cannot be used. This causes thumb flexion rather than extension.
http://www.mims.com/resources/drugs/common/CP0042.gif
http://www.youtube.com/watch?v=yJTIhm1VfSI
Risk stratisfication score introducted by Maden Samuel in 2002.
The Pediatric Appendicitis Score had a sensitivity of 1, speciificity of 0.92, positive predictive value of 0.96, and negative predictive value of 0.99
Signs:
Symptoms:
Laboratory Values:
Scores of 4 or less are least likely to have acute appendicitis, while scores of 8 or more are most likely.
In June 2013 the American College of Medical Toxicology (ACMT) released a Guidance Document on the Management Priorities in Salicylate Toxicity. Here are some key highlights:
The full document can be accessed here.
The Poison Review blog by Dr. Leon Gussow discusses the guidance document here.
Follow me on Twitter (@PharmERToxGuy)
3 year-old male develops rash 5 days after starting amoxicillin for acute otitis media. What's the diagnosis?
A recent, randomized study evaluated two approaches for treating acute pain in an inner-city ED.
Application to clinical practice: For most patients with acute, severe pain in the ED, start with hydromorphone 1 mg. It may be all the patient needs and can potentially avoid giving them extra opioid they don't need.
Background:
Infection with the Hepatitis C virus can result in mild to severe liver disease. Morbidity and mortality from Hep C is increasing the US--many of the 2.7-3.9 million persons with Hep C are not aware of their infection.
Pertinent Information:
- Hepatitis C is now curable for many patients
- Current treatment recommendations are a combination of medications (pegylated interferon plus ribavirin plus a protease inhibitor).
- Research in this field is very active--treatment is likely to change in the next 3-5 years.
- Risk reduction strategies to protect the liver (i.e. eliminating alcohol and Hep A and B vaccination) are also recommended.
Critical New Recommendation
As much of the disease burden is in the “Baby Boomers,” the CDC now recommends one time testing of all persons born between 1945 and 1965.
Bottom Line:
While emergency department management is focused on the treatment of acute complications of liver disease, it is also important to have all age appropriate patients follow-up for testing and treatment of Hepatitis C with their primary care provider.
Hydroxyethyl starch (HES) is a colloid used for volume resuscitation in critically-ill patients.
Previous studies (click here) have compared crystalloids to HES during fluid resuscitation and have demonstrated that HES has an increased cost with more adverse effects. Adverse effects may include:
In the United States, the Federal Drug Administration published a warning on June 24th 2013 with respect to the use of HES in critically ill adult patients. Specifically, it warned about the use of HES in patients,
If a decision to use HES is made, the FDA warning advises to:
Bottom line: With an increased cost and evidence of harm compared to crystalloids, it appears the indications for use of HES are rapidly declining.
65 year-old male presents with nausea and diffuse abdominal pain, 3 days after knee replacement surgery. What's the diagnosis?
Sternal fractures
When reviewing a patient's medication list, there are always some that should catch your eye. Digoxin is one since we can measure it, has a low therapeutic index and elimination is effected when renal function is diminished. Another drug that should catch your eye is SOTALOL. Renally cleared and affected by even a minimally lower than normal magnesium. The toxic effect even at therapeutic levels is torsades de pointes.
One study, in a 736 bed hospital, showed 89% of patients prescribed sotalol were on an inappropriate dose due to renal function and an odds ratio of 3.7 increased re-admission rate at 6 months for the patients on the inappropriate dose of sotalol.
We can catch this in the ED. Involve your pharmacist, ED pharmacist or local toxicologist for dosing calculations.
General Information:
An estimated 70 children in the world die every 5 minutes-- 99% of these deaths are from developing countries, half in Sub-Saharan Africa , and two-thirds from preventable or easily treatable causes.
Area of the world affected:
One study examining the quality of hospital emergency care of 131 children in 21 hospitals in 7 developing countries found:
· 66% of hospitals did not have adequate triage; 41% of patients had inadequate initial assessment;
· 44% received inappropriate treatment and 30% had insuf cient monitoring.
· Frequent essential drugs, laboratory and radiology services supply outages
· Staffing and knowledge shortages for medical and nursing personnel
Relevance to the US physician:
The International Federation of Emergency Medicine (IFEM) used a consensus approach to develop the International Standards for Emergency Care of Children in Emergency Departments, published in July 2012.
· The standards covering initial assessment, stabilization and treatment, staf ng and training
· Guidelines for coordinating, monitoring and improving the pediatric emergency care are addressed
Bottom Line:
The IFEM International Standards for Emergency Care of Children provide an excellent resource for both clinicians and hospital managers in developing countries.
University of Maryland Section of Global Emergency Health
Author:Terrence Mulligan DO, MPH,FIFEM, FACEP, FAAEM, FACOEP, FNVSHA
--thanks and acknowledgments to Baljit Cheema, University of Cape Town and Stellenbosch University, South Africa
