Revisits back to the ED within 3 days of the initial visit represent a standard quality measure. A critical ED revisit was defined as an ICU admission or death within 3 days of ED discharge. This study looked at 16.3 million children who were discharged from various EDs over a 4 year period and found that 0.1% (18,704 patients) had a critical revisit and 0.00001% (180 patients) died.
The most common diagnosis at the initial visit of those patients coming back with a critical revisit included: Upper respiratory infections, gastroenteritis/nausea/vomiting and asthma.
The most common critical revisit diagnosis were: asthma, pneumonia, cellulitis, bronchiolitis, upper respiratory infections, respiratory failure, seizure, gastroenteritis/nausea/vomiting, appendectomy and sickle cell crisis. Among the patients who died, 48.9% were younger than 4 years. Patients with complex medical problems and patients seen at a high volume center were more likely to have a critical ED visit.
Bottom line: These ED revisits may not have been related to missed diagnosis (with the exception of appendicitis), but rather due to the natural progression of certain disease processes. Patients with these diagnoses may benefit from careful reassessment, targeted patient education, more specific return precautions and closer outpatient follow up.
IVC POCUS is often misapplied in attempts to assess volume status and/or volume “responsiveness.” Here are some important concepts to understand when using IVC POCUS to guide management:
The 2nd most common reason for EMS activation is chest pain. In this study, paramedics were asked to complete the HEAR (history, EKG, age, risk factor) score, EDACS (ED Assessment of chest pain score), the Revised Geneva Score and the PERC (Pulmonary embolism rule-out criteria) for all patients older than 21 who presented with chest pain. The positive and negative likelihood ratios (LR) of the risk scores in relation to 30 day MACE and PE risk were calculated.
837 patients were included in this study with 687 patients having all 4 scores completed. The combination of HEAR/PERC had the best negative LR (0.25) for ruling our MACE and PE at 30 days. However, these scores, alone or in combination, were not sufficient to exclusively guide treatment or destination decisions. Adding biomarkers (ie troponin or Ddimer to the prehospital setting) could improve the usefulness of these scores.
What are the signs of Cardiac Tamponade on ultrasound?
Think of them as a pyramid with clinical importance decreasing as you rise to the top of the pyramid.
To have tamponade you need a pericardial effusion.
The most specific sign of tamponade is RV collapse in diastole.
The earliest and most sensitive sign is RA collapse over 1/3 of the cardiac cycle from late diastole into systole, which is why we say RA collapse during systole.
IVC dilation also occurs but is not sensitive.
Placing the pulse wave Doppler over the mitral valve and evaluating the change with respirations is an advanced technique. It’s positive if you have 25% change.
Don’t know if you are in systole or diastole? Connect your telemetry leads to the ultrasound machine. Don't have leads? Then you can also cine scroll on a subxiphoid view or parasternal view to look at when the valves are open and closed, then compare to the cardiac wall positioning.
Imagine lying in a bed staring at the ceiling and these fuzzy faces looking down on you clearly saying something to you but you can't hear them while your hip and pelvis are hurting worse than anything you have ever felt. That's what many of our fall from standing elderly patients experience in emergency departments on a regular basis. Do not remove glasses or hearing aides from your elderly patients. Work with our EMS colleagues to make it a practice to bring glasses and hearing aides along from the scene. Speak slowly and get close to their ear to help if necessary. That confusion, delirium or dementia you assume this patient has is actually just hearing impairment and poor vision.
Wrist pain in golfers
70% of amateur golfers will experience a sport related injury in their lifetime.
The hand/wrist is the third most common body area injured by golfers after the back and elbow.
Studies fail to include multi trauma from golf cart accidents:)
Wrist injuries are 3x more frequent than hand injuries.
Wrist injury affects 13 to 20 percent of amateur golfers.
Injury is most likely to occur at the point of ball impact.
Injury most commonly affects the lead wrist rather than the trail wrist.
The lead wrist is left sided for right-handed players and right sided for lefties
Due to many differences in grip and wrist position there are several injury patterns.
Most causes of wrist pain in golfers are tendinopathies.
Due to impact stress and repetitive swinging movements
If pain is primarily radial, consider DeQuervain's tenosynovitis
Poor swing mechanics such as premature wrist uncocking in the early downswing places the wrist in ulnar deviation thereby stressing the first dorsal compartment.
Significant ulnar deviation of the lead wrist at time of ball impact may also stress the tendons of the first dorsal compartment.
If pain is primarily ulnar consider Extensor Carpi Ulnaris tendonitis & subluxation
A strong golf grip (more knuckle’s visible) is associated with greater ECU stress during the swing
The height of hand position can also stress the ECU tendon
Differential diagnosis:
TFCC injury
Hook of hamate fracture
Carpal Tunnel Syndrome
Ulnar Tunnel Syndrome
Nirmatrelvir-ritonavir (Paxlovid™) is a combination of two protease inhibitors used for the treatment of mild-moderate symptomatic COVID-19. Nirmatrelvir inhibits the SARS-CoV2 main protease, and ritonavir inhibits metabolism of nirmatrelvir, acting as a “booster” to increase nirmatrelvir concentrations.
The EPIC-HR trial, which included non-hospitalized adults with mild-moderate COVID-19 who were unvaccinated and at risk of progressing to severe disease, showed an 89% reduction in COVID-19-related hospitalization or 28-day all-cause mortality in patients treated with nirmatrelvir-ritonavir compared to placebo. The efficacy rates in this trial were similar to remdesivir (87% relative risk reduction), and greater than molnupiravir (31% relative risk reduction), two alternative agents used for treatment of mild-moderate COVID-19. However, these three agents have never been directly compared. Nirmatrelvir-ritonavir was initially approved by the FDA under Emergency Use Authorization (EUA), but is now fully FDA-approved as of May 2023.
Which patients benefit?
Drug-Drug Interactions:
Dosing:
Common side effects:
Bottom Line: Paxlovid is appropriate for patients with symptomatic mild-moderate COVID-19 with risk factors for progression to severe disease. Ask your pharmacist for assistance evaluating drug-drug interactions!
This retrospective cohort study examined patients over a one year period to evaluate factors associated with unfavorable outcomes in acute abdominal pain.
Unfavorable outcomes were defined as any of the following: 1) shock requiring an invasive procedure such as central line insertion or mechanical ventilation 2) emergency surgery 3) post-operative complications OR 4) in-hospital cardiac arrest
951 patients were included in the study.
Physical exam and laboratory signs associated with the above unfavorable outcomes included:
-diastolic BP < 80 mmHG
-RR ? 24/min
-RLQ tenderness
-abd distension
-hypoactive bowel sounds
-presence of specific abdominal signs (ie Murphy's sign, psoas sign, etc).
-leukocytosis
-ANC >75%
Further, ED Length of Stay of > 4 hours was also associated with unfavorable outcomes.
Food for thought when considering serial abdominal exams when diagnosis is unclear…
Many of us in the endovascular resuscitation space were eagerly awaiting some clarity on REBOA from this trial. Unfortunately, this is not the definitive trial that either confirms or denies the utility of REBOA in trauma.
Unfortunately, even this well-designed trial suffered from major problems, most notably enrollment issues (ITT: of the 46 in the REBOA group, only 19 actually got REBOA!!) and matching issues (Brain AIS was significantly higher in the REBOA group versus standard practice [3 vs 0] & initial systolic pressure was lower in the REBOA group, both of which are known risk factors for poor outcome in REBOA).
This trial's failure to provide a definitive benefit or the nail-in-the-coffin is frustrating to say the least. Until that day, we will continue to be selective of the "right" patient and to put in femoral arterial lines early and often.
Zaf Qasim has an excellent talk on EMRAP about this study, as does St. Emlyn's.
BACKGROUND:
Critical care transport teams are tasked with extending specialized care to the bedside. Given the uptick in COVID and ARDS cases, there are increasing demands for the transport of patients proned for respiratory compromise. An air medical service in British Columbia (BC) published their experience with transporting intubated patients in the proned position. The BC service utilizes 2 trained flight paramedics and conducts transports via pressurized fixed wing and non pressurized rotor wing aircraft. The small, retrospective study of 10 patients demonstrated feasibility of this practice. No extubations were recorded in the study population. 6/10 patients experienced >6% increase in oxygen saturation and no medical lines were disconnected during transport.
BOTTOM LINE:
BALTIMORE, MD SPECIFIC PEARL:
BONUS AVIATION ENTHUSIASTC SPECIFIC PEARL:
Approaching patients based on their frailty, not their age, leads to better medical decision making. A recent best practice guideline from the American College of Surgeons sums up frailty:
“It is well recognized that aging is associated with physiological decline, but this decline is not uniform across all individuals or even across one individual’s organ systems. Frailty is a geriatric syndrome, clinically distinct from age, comorbidity, and functional disability, characterized by age- associated depletion of physiological reserves that leads
to a state of augmented vulnerability to physical stressors and a diminished ability to recover from illnesses.” A trauma specific frailty index exists to identify these high risk patients.
Since 2014, Medicare has payed for inpatient services for Medicare patients who’s admitting physician noted that hospital stay required at least 48 hours (measured as 2 midnights) or required specialty care that could not be performed as an out patient. This rule now will apply to Medicare Advantage insurance patients as well. Physicians will need to document their reasoning why a patient’s stay will likely require two midnights.
As is well known, fluid resuscitation strategy ("liberal" vs “restrictive”) in sepsis is a controversial topic. An RCT in NEJM called CLOVERS that looked at this and found no difference was recently re-analyzed to answer the following question… should my choice of strategy change if the patient presents with an Acute Kidney Injury (AKI)?
For the most part, the answer is no. In the group with AKI, the restrictive group did slightly, but non-statistically-significantly, better. Interestingly, in the group without AKI, the relationship reversed, and in fact of the 4 groups (AKI vs no AKI, Restrictive vs Liberal), the no AKI but liberal strategy group did best (liberal vs restrictive in the no AKI group almost reached statistical significance in favor of the liberal strategy, but not quite).
Bottom Line: In septic patients presenting with an AKI, we don't know whether liberal or restrictive strategy is better, but either is probably reasonable. In patients presenting without an AKI, it may be more ok to lean more towards liberal fluid resuscitation than in non-AKI patients*.
*There are several important caveats here: 1) they didn't closely evaluate for potential side effects of over-resuscitation such as hypoxia or pulmonary edema (the primary outcome was need for renal replacement therapy), 2) as mentioned above, this trended towards but did not reach statistical significance, 3) this is one small study which did a subgroup secondary-analysis of a larger trial.
As the calendar flips to a new year, consider not setting goals or resolutions. Studies show unmet goals or having too many half finished projects leads to increased stress, anxiety and depression. Instead, consider approaching the new year looking for growth, introspection, and striving to achieve excellence. Understanding the why and what motivates you will lead to the correct what and how. Here are some questions to get you thinking about the why. May your New Year be filled with growth and excellence!
For the agitated geriatric patient, if verbal deescalation, distraction, and providing a safe quiet area do not work and you require chemical sedation use oral antipsychotics first. Follow this with IV or IM antipsychotics. Avoid benzodiazepines due to often worsening delirium or respiratory depression. For dosing, start low and go slow.
NEXUS criteria for blunt chest trauma patients who are over 14 years old, not intubated:
>60 years old
rapid deceleration defined as fall > 6 meters or motor vehicle crash >64 km/hour
chest pain
intoxication
abnormal alertness or mental status
distracting painful injury
tenderness to chest wall palpation
If abnormal chest X-Ray proceed to chest CT. Negative predictive value of 99.9% excluding major injury.
Estimating the size of knee effusions
While this size range is typically easily detectable on exam. This may not apply to patients who are either very muscular or obese.
If the detection of a small to moderate sized effusion would change patient management
Consider ultrasound:
As compared to MRI (sensitivity of 81.3 % and a specificity of 100 %)
US hospitals have traditionally been concerned that without an ambulance diversion protocol that they would be overrun with EMS arrivals. EMS had been concerned that without diversion there would be extended wait times at the hospital. This study looked at EMS arrivals one year (2021) before the elimination of diversion and compared the number to one year after diversion elimination (2022).
This study of a single level 1 trauma center showed that there was NO difference between the number of EMS arrivals per day (84 vs 83, p = 0.08), time to room for ESI 2 patients, time to head CT in acute stroke patients OR ambulance turn around time (16 min vs 17 min, p = 0.15).
Acute-On-Chronic Liver Failure
By performing a Point-of-Care Transvaginal Ultrasound (TVUS), we can decrease length of stay for patients with early pregnancy. Moreover, if an ectopic pregnancy is identified, we can decrease time to the OR for these patients.
Begin by discussing the exam with the patient and ensuring they have emptied their bladder. Apply a probe cover and add sterile lubricant to the outside of the probe tip. You can save time by performing a TVUS immediately after the pelvic speculum exam for swab collection.
Gently introduce the transducer with the marker upward, directed towards the ceiling. As you slowly advance, the uterus will be visualized in a sagittal orientation. Fan through the uterus by moving the probe handle left and right.
Image From: doi: 10.1016/j.emc.2022.12.006.
Rotate the transducer so that the marker is directed towards the patient's right side. Fan through the uterus by lifting the probe handle up and down.
Image From: doi: 10.1016/j.emc.2022.12.006.
If a gestational sac is found, you should measure the gestational age and if present, fetal heart rate.
Tilt the transducer towards the patient's left or right side to visualize the adnexa. The adnexa will be located medially to the iliac vessels.
Remove the transducer and follow your department protocol for high level disinfection.
