Category: Critical Care
Keywords: Geriatrics, infections, ICU, pneumonia (PubMed Search)
If you have an intuition your patients older than 65 are at increased risk of infection, especially pneumonia (4-11 times the risk of the under 65 cohorts), you are correct.
If you are concerned your patients co-morbidities, such as COPD, heart disease, and malnutrition will contribute to prolonged mechanical ventilation (the rate of VAP increases 1-3% every extra day on the vent), you are correct.
After age 70, the ICU length of stay and duration of mechanical ventilation increase by 5 days and 9 days respectively.
In the age of COVID-19, itself associated with prolonged mechanical ventilation, it's fair to prepare patients and families for this. We are fortunate we do not need to ration ventilators, so our discussions remain centered on the wishes of our patients, informed by a realistic understanding of what treatment and recovery entail.
Esme M, Topeli A, Yavuz B, et al. Infections in the Elderly Critically-Ill Patient. Frontiers in Medicine 2019; 6: 118.
Category: Pharmacology & Therapeutics
Keywords: acute kidney injury (PubMed Search)
Short periods of AKI have been linked to prolonged hospitalizations, development of CKD/ESRD and in-hospital mortality. Historically, AKI in the ED has been studied with respect to the receipt of contrast media with little data available on nephrotoxic medications.
A recent 5-year retrospective cohort study sought to determine the impact of prescribing nephrotoxic medications in the ED and the development of AKI within 7 days defined as an increase in SCr of ≥ 0.3 mg/dL or 1.5 x baseline. The categories of potentially nephrotoxic medications included ACE-i/ARB, antibiotics, diuretics, NSAIDs, and other (antifungal, antineoplastic, and antivirals).
Inclusion: Adult patients ≥ 18 years, with an initial and repeat SCr measured 24-168h after the initial test, under admitted or observation status (discharged patients were included if they had a repeat SCr in the time window).
Exclusion: previous hospital or ED visit within 7 days, initial SCr < 0.4 mg/dL, initial SCr > 4.0 mg/dL, missing data, dialysis, or transplant history.
The authors assessed 46,965 hospitalized encounters and found that 13.8% of patients developed AKI. Risk factors included older age, African American patients, history of CHF or CKD, higher initial SCr, and higher complexity and mortality. AKI developed within 48 hours in half of the patients and the reminder did so by 120 hours. Approximately 22% had ≥ 1 potentially nephrotoxic medication administered and 6% had ≥ 2 classes.
Diuretics were associated with the highest risk of AKI (64% increased risk), followed by ACE-i/ARBs (39%), and antibiotics (13%). NSAIDs were not associated with an increased risk. The antibiotics associated with the highest risk of AKI were piperacillin-tazobactam, sulfamethoxazole-trimethoprim, and quinolones.
Bottom Line: Medications prescribed in the ED have an impact on the development of AKI during hospitalization. While these cannot always be avoided, use caution when combining multiple nephrotoxic medications and discontinue therapy early when feasible.
Hinson J, et al. Risk of acute kidney injury associated with medication administration in the emergency department. J Emerg Med. 2020;58(3): 487-496.
Keywords: antiseptics, disinfectants, sterilants (PubMed Search)
Recently, “disinfectants,” or germicides, has gain public attention during COVID-19 pandemic. So, what types of agents are considered as “disinfectants?”
Germicides as classified into three broad categories
1. Antiseptics – chemicals applied to living tissue to kill or inhibit microorganisms
a. Iodine & iodophors (e.g. Povidone-iodine; aka Betadine)
b. Chlorine, bleach (sodium hypochlorite)
d. Hydrogen peroxide
e. Alcohols (ethanol and isopropanol)
2. Disinfectants – chemicals applied to inanimate objects to kill or inhibit microorganisms
b. Phenol (aka carbolic acid)
c. Substituted phenols (e.g. hexachlorophene; aka pHisoHex)
d. Quaternary ammonium compounds (benzalkonium chloride; aka Zephiran)
3. Sterilants – chemicals applied to inanimate objects to kill all microorganisms including spores
a. Ethylene oxide
Although ethanol is frequently found in alcoholic beverage and consumable, no other chemicals should be ingested or injected.
Category: Critical Care
Vitamin C for Septic Shock?
Fujii T, et al. Effect of vitamin C, hydrocortisone, and thiamine vs hydrocortisone alone on time alive and free of vasopressor support among patients with septic shock. JAMA. 2020. epub Jan 17.
Keywords: ibuprofen, analgesia, pain (PubMed Search)
Comparison of Oral Ibuprofen at Three Single-dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial
Ibuprofen is one of the most commonly used medications in the ED for the acute treatment of pain. Analgesic ceiling doses are not well supported. Some adverse effects of NSAIDs are dose dependent (GI and cardiovascular).
A recent study looked to compare the analgesic effect of oral ibuprofen at 3 different doses
Population: Adult ED patients (aged 18 and older) with acute pain.
Methods: Randomized double-blind trial.
Goal: To examine the efficacy of ibuprofen at 400, 600 and 800mg.
Only 225 patients enrolled (75 per group). Outcome was difference in pain scores at 60 minutes.
Results: Difference in mean pain scores at 60 minutes between 400 and 600mg (0.14), 400 and 800mg (0.14) and 600 and 800mg (0.00).
Conclusion: Reduction in pain scores was similar between all 3 dosing groups. Consider lower dosing of ibuprofen in ED patients presenting with acute pain.
This analgesic ceiling dose is lower than recommended by the FDA and most EM textbooks.
Consider using the 400mg ibuprofen dose for ED patients with acute pain
Motov et al., 2019. Comparison of Oral Ibuprofen at Three Single-dose Regimens for Treating Acute Pain in the Emergency Department: A Randomized Controlled Trial. Annals of Emergency Medicine. Oct 2019.
Keywords: traumatic brain injury, intracranial pressure, cervical collar, immobilization (PubMed Search)
Bottom Line: Cervical collars can increased ICP in moderate-severe TBI. In patients with poor cerebral compliance and impaired cerebral autoregulation, even a small increase in ICP can affect cerebral perfusion.
Nunez-Latino RA, Rubiano AM, Godoy DA. Impact of cervical collars on intracranial pressure values in traumatic brain injury: a systematic review and meta-analysis of prospective studies. Neurocrit Care. 2020;32(1):469-77.
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Keywords: buprenorphine, CYP3A4, induction, inhibition, metabolism (PubMed Search)
Buprenorphine (BUP) is increasingly prescribed/used to treat opioid use disorder (OUD) in the United State. BUP is mainly metabolized by CYP3A4 where its enzymatic activity can be either induced or inhibited by many agents.
For example, a study showed that Rifampin administration for 15 days, a potent 3A4 inducer, resulted in (1):
On the contrary, exposure to voriconazole – strong 3A4 inhibitor - resulted in (n=12 health volunteers) (2):
Cannabis use – (CBD is a CYP 3A4 inhibitor) also increased the BUP concentration by 2.7 fold. (3)
1. Drug Alcohol Depend. 2011 Nov 1;118(2-3):326-34. doi: 10.1016/j.drugalcdep.2011.04.013. Epub 2011 May 19.
Rifampin, but not rifabutin, may produce opiate withdrawal in buprenorphine-maintained patients.
2. Eur J Clin Pharmacol. 2018 Dec;74(12):1615-1622. doi: 10.1007/s00228-018-2548-8. Epub 2018 Aug 30.
Voriconazole greatly increases the exposure to oral buprenorphine.
3. Eur Arch Psychiatry Clin Neurosci. 2020 Jan 6. doi: 10.1007/s00406-019-01091-0. [Epub ahead of print]
Buprenorphine-cannabis interaction in patients undergoing opioid maintenance therapy.
Category: Critical Care
Keywords: status epilepticus, anticonvulsant medications, fosphenytoin, levetiracetam, valproate (PubMed Search)
Title: Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus
Outcome: absence of clinical seizure at 60 minutes after infusion of medication.
Kapur J, Elm J, Chamberlain JM, Barsan W, Cloyd J, Lowenstein D, Shinnar S, Conwit R, Meinzer C, Cock H, Fountain N, Connor JT, Silbergleit R; NETT and PECARN Investigators.
Randomized Trial of Three Anticonvulsant Medications for Status Epilepticus. N Engl J Med. 2019 Nov 28;381(22):2103-2113. doi: 10.1056/NEJMoa1905795.
Keywords: MVC, anticipatory guidance, seatbelts. (PubMed Search)
The leading cause of death in the US for those aged 16 to 24 years is motor vehicle collisions (MVCs). Teen drivers are more likely than any other age group to be involved in an MVC that result in injury or fatality. Texting while driving, nighttime driving, inexperienced driving, and driving under the influence of alcohol or drugs may play a role in these collisions.
Can anticipatory guidance related to safe driving be done in the ED? YES!
This study implemented a toolkit that contained a copy of the driving law, a sample parent-teen driving contract and statistics on teen driving injuries. Post toolkit questionnaires showed that both teens and their guardians learned new information.
Bottom line: Engage in anticipatory guidance in the ED with teens and their parents about seatbelt use, the dangers of driving under the influence and local driving laws.
Spears et al. Teen driving education in the pediatric emergency department: effectiveness of a tool kit. Southern Medical Journal 2019; 112(11): 562-565.
Category: Critical Care
Clinical Question: Does a lower MAP target (60-65 mmHg) for ICU patients ≥ 65 years-old reduce 90-day mortality?
-Design: multicenter (across 65 UK ICUs), randomized clinical trial (not blinded), ultimately with 2598 patients
-Inclusion criteria: ICU patients ≥ 65 years-old receiving vasopressors for vasodilatory hypotension with adequate fluid resuscitation
-Exclusion criteria: vasopressors being solely used for bleeding or acute RV/LV failure or post-cardiopulmonary bypass vasoplegia, ongoing treatment for brain/spinal cord injury, death perceived as imminent
-Patients in the permissive hypotension group had a lower exposure to vasopressors compared with those in the usual care group
-Mean MAP was on average 6 mmHg lower in permissive hypotension group
-At 90 days, there was no statistically significant difference in all-cause mortality
-No significant difference in mean duration of ICU and hospital stay, duration and days alive and free from advanced respiratory and renal support to day 28
-No significant different in number of serious adverse events (severe acute renal failure, supraventricular and ventricular cardiac arrhythmia, myocardial injury, mesenteric ischemia, and cardiac arrest)
A lower MAP goal of 60-65 mm Hg appears to be safe for ICU patients ≥ 65 years-old being treated for vasodilatory hypotension
Lamontagne F, Richards-belle A, Thomas K, et al. Effect of Reduced Exposure to Vasopressors on 90-Day Mortality in Older Critically Ill Patients With Vasodilatory Hypotension: A Randomized Clinical Trial. JAMA. 2020;
Keywords: Analgesia, muscle injury, pain control (PubMed Search)
A recent study looked at analgesic prescribing patterns for patients with back pain in EDs in the United States.
Back pain is the most common pain complaint worldwide
-Accounted for about 9% of all ED visits.
In 2007, overall opioid use was 53.5%; in 2016, it was 46.5% (P=0.001). The largest drop was in hydrocodone use.
A recent study in JAMA looked at the risk of death in 90,000 people one year after filling a Rx for tramadol vs. one of several other analgesics such as naproxen, diclofenac or codeine.
All patients were aged 50 years or older and has osteoarthritis.
Initial Rx for tramadol was associated with a higher rate of mortality than with NSAIDs (but not compared to codeine).
Zeng et al., 2019. Association of Tramadol With All-Cause Mortality Among Patients With Osteoarthritis. JAMA 2019 March 12;321(10):969-982.
Mullins et al., 2020. Trends in Evaluation and Management of Back Pain in United States Emergency Departments (2007-2016). AAAPM 2020.
Category: Critical Care
Keywords: Acute respiratory failure, respiratory distress, Coronavirus, COVID-19, SARS-CoV-2 (PubMed Search)
There is currently a high, and appropriate, concern regarding the aerosolization of viral particles during various methods of respiratory support. While studies are limited, here is some of the currently available data (mostly-simulated) on the approximate maximum distances of particle spread:
Nasal Cannula 5LPM:1 1 ft 4.5 in
Non-Rebreather Mask, 6-12LPM: 4 in, minimal change with increasing flows1
High Flow Nasal Cannula
CPAP (20 cmH2O) provided by oronasal mask with good fit (leak from exhaust port):2 11.5 in
Bilevel positive airway pressure w/ oronasal mask (IPAP 10-18/EPAP 4): max dispersal:4 1 ft 7.7 in
Bilevel positive airway pressure with full facemask5 (IPAP 18 / EPAP 5): 2 ft 8 in
Bilevel positive airway pressure with helmet:4
Utility of Surgical Mask:6
In vivo data from actual patients is lacking, however there is potentially lower risk of aerosol spread with HFNC than regular nasal cannula, perhaps due to higher likelihood of a tighter nare/nasal cannula interface. Nonrebreather mask performs well indirectly with the shortest dispersal distance. Noninvasive positive pressure ventilation with an oronasal mask and good seal has a relatively short dispersal distance, and a surgical mask over respiratory support interventions actively decreases amount, if not distance, of particle spread. Use of appropriate PPE and negative pressure rooms, if available, remains key.
A 7 year-old Spanish speaking female presents to the emergency room after ingestion of 2 – 3 tablets of her sister’s medication. She complains of nausea/vomiting with diarrhea, periorbital/facial swelling, and flushing of her skin. Her urine is reddish but there is no blood is shown in urinalysis/urine microscopic analysis. The patient's sister is taking the medication for a respiratory condition.
Which medication did she take?
Rifampin is often used to treat tuberculosis as part of a combination therapy. It inhibits RNA chain polymerization in mycobacteria. Rifampin also has significant drug-drug interaction issue due to induction of CYP3A4, 1A2, 2C9 and 2C19.
Isolated rifampin ingestion infrequently leads to serious toxicity.
Common symptoms of acute toxicity include:
Management of acute toxicity is mainly supportive.
Keywords: cyclopeptide, mushroom poisoning, fatality rate (PubMed Search)
Cyclopeptides (Amatoxin)-containing mushroom poisoning results in delayed development of gastrointestinal symptoms that may progress to liver failure. There is no established antidotal treatment for cyclopeptide-induced hepatic failure; silibinin is currently under investigation.
There is a wide range of case fatality reported from cyclopeptides-containing mushroom poisoning: 4.8% to 47%.
National Poison Data System was reviewed from 1/1/2008 to 12/31/2018 for all suspected cyclopeptides containing mushroom poisoning. Out of 8953 suspected cases, 148 cases were included in the study.
De Olan J et al. Current fatality rate of suspected cyclopeptide muschroom poisoning in the United States. Clin Toxicol (Phila.) 2020. DOI: 10.1080/15563650.2020.1747624
Category: Critical Care
Keywords: HLH, Hemophagocytic Lymphohistiocytosis (PubMed Search)
Please see Part I from 12/24/19 for information about causes and symptoms.
The diagnosis of HLH is challenging, as it often mimics sepsis or other critical illness. A high index of suspicion is vital and early treatment, imperative.
Diagnostic criteria in adults include 5 of 8 of the following:
(based on the Hscore: https://www.mdcalc.com/hscore-reactive-hemophagocytic-syndrome#use-cases)
· Presence of known immunosuppression
· Fever >38.5
· Splenomegaly or hepatomegaly
· Ferritin elevation (usually markedly elevated)
· Elevated triglycerides
· Low fibrinogen level
· ALT elevation
· CD25 levels are elevated
· NK cell activity is low or absent
In adults, highly elevated ferritin levels (>10,000) are highly suggestive of HLH.
Elevated LDH, Ddimer, and multisystem organ dysfunction (especially CNS) is common.
Immunologic testing should not delay treatment if other lab values suggestive of HLH.
Given the high mortality rate, treatment should be initiated if the symptoms are suggestive of HLH. In the setting of a critically ill individual, hematology consultation is warranted for treatment guidance as treatment is based on lab values and clinical picture. Treatment usually starts with high dose , IV steroids (dexamethasone) and may include chemotherapeutic agents, such as Etoposide. For those patients with CNS involvement, intrathecal chemotherapy is usually a mainstay of treatment
Keywords: Dislocation, fracture (PubMed Search)
Studying the demographics of all both sports and recreation related injuries is important for the development of effective preventive strategies.
Methods: National electronic injury surveillance system all injury program from 2005 to 2013 (367,300 sports and recreation related ED visits).
18 common sports and recreational activities in the United States
Results: A fracture occurred in 20.6% and a joint dislocation in 3.6% in ED visits for a sport related visit
Most of the fractures occurred in football (22.5%) and occurred in autumn and summer. Most fractures occurred in arm/hand (finger most common). Most fractures occurred in school or sporting venues.
The OR for fracture was greatest for inline skating (6.03), males (1.21) and those between 10 and 14 years of age and those older than 84 years (4.77).
Dislocations were highest in basketball (25.7%) and occurred in the autumn and on weekends. Most dislocations occurred in school or sporting venues.
The OR for dislocation was greatest in gymnastics (4.08), males (1.50) and those aged 20 to 24 years (9.04)
The most common fracture involved the finger and the most common dislocation involved the shoulder, followed by finger and knee.
The Demographics of Fractures and Dislocations Across the Entire United States due to Common Sports and Recreational Activities. Sports Health. 2020 Mar/Apr;12(2):159-169.
Keywords: chloroquine, hydroxychloroquine (PubMed Search)
COVID-19 pandemic has brought two old medications – chloroquine and Hydroxychloroquine – back from the past.
A couple in Arizona self-medicated with chloroquine this week and experienced chloroquine toxicity; the man died and his wife was admitted to the ICU.
Chloroquine and hydroxychloroquine overdose result in cardiotoxicity by Na and K channel blockade (similar to other membrane stabilizing agents such as TCAs, loperamide, etc.). Onset of toxicity is usually within 1 – 3 hours after ingestion.
Other symptoms of toxicity include: nausea/vomiting, respiratory depression/apnea, altered mental status and seizure. Hypokalemia is often encountered.
Use of sodium bicarbonate is controversial due to worsening of hypokalemia. Instead, administration of high dose diazepam and epinephrine (EPI) infusion has shown to decrease mortality (see below).
Riou B et al. NEJM 1988 DOI: 10.1056/NEJM198801073180101
Clemessy JL et al. Crit Care Med 1996. DOI:10.1097/00003246-199607000-00021
Treatment: 87% received at least one of the interventions below.
Keywords: Coronavirus, SARS, SARS-CoV, COVID-19, SARS-CoV-2 (PubMed Search)
Bottom Line: SARS-CoV has been associated with CNS involvement. Given their similar pathogenesis and finding of hyposmia in COVID-19, SARS-CoV-2 may be associated with risk of CNS involvement.
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Category: Critical Care
Keywords: COVID-19 (PubMed Search)
Within the past few days we completed a review of complications of COVID-19, to describe what sequelae and clinical patterns, besides the obvious (URI, respiratory failure, ARDS, sepsis, etc), are noted in the literature. This review, along with a plethora of other information focusing on critical care of the COVID-19 patient, will be posted in the next few days to http://covid19.ccproject.com/. Below are the key points from that review:
Acute cardiovascular complications appear to be the most common and concerning sequelae:
-Acute myocardial injury (7-17% of hospitalized patients in one study),
-Myocarditis (primary cause of death in 7% of COVID deaths in one study),
-Arrhythmias (16.7% of hospitalized and 44.4% of ICU patients in one study),
-Venous thromboembolism (incidence unknown).
Concerns for sudden cardiac death, even after recovery, have been raised but are not well documented in the literature. Proposed mechanisms include respiratory compromise, myocarditis, malignant tachydysrhythmias, heart failure, and coronary plaque instability (i.e. Type 1 MI) secondary to inflammation
Co-infection and secondary infection rates are unknown but estimates range from 4.8% to 21%, with higher rates in sicker patients. Viral co-infection is more common than bacterial co-infection, but both may be seen. The ability to rule out COVID-19 by a positive multiplex respiratory viral panel is questionable.
Cytokine release syndrome and secondary HLH are both described complications, but their incidence is unknown. The relation of this finding to purported benefits of tocilizumab (which is also a therapy for HLH) is unknown.
Other extrapulmonary complications are relatively typical of sepsis, such as kidney injury, abnormal LFTs, and delirium
If anyone would like a copy of the full document, which details known complications by organ system, please feel free to email me at email@example.com. Thanks to David Gordon for organizing the project.
Everyone stay safe, and be sure to take care of each other, as well as our patients.
Keywords: pandemic, coronavirus, pediatric (PubMed Search)