Category: Critical Care
Keywords: CPR, Cardiac Arrest (PubMed Search)
It is well documented that when left to our own respiratory devices we will consistently over-ventilate patients presenting in cardiac arrest (1). A simple and effective method of preventing these overzealous tendencies is the utilization of a ventilator in place of a BVM. The ventilator is not typically used during cardiac arrest resuscitation because the high peak-pressures generated when chest compressions are being performed cause the ventilator to terminate the breath prior to the delivery of the intended tidal volume. This can easily be overcome by turning the peak-pressure alarm to its maximum setting. A number of studies have demonstrated the feasibility of this technique, most recently a cohort in published in Resuscitation by Chalkias et al (2). The 2010 European Resuscitation Council guidelines recommend a volume control mode at 6-7 mL/kg and 10 breaths/minute (3).
1. Aufderheide TP, Sigurdsson G, Pirrallo RG, Yannopoulos D, McKnite S, von Briesen C, Sparks CW, Conrad CJ, Provo TA, Lurie KG. Hyperventilation-induced hypotension during cardiopulmonary resusci- tation. Circulation. 2004;109:1960 –1965.
2. Chalkias, Athanasios et al. Airway pressure and outcome of out-of-hospital cardiac arrest: A prospective observational study. Resuscitation. November 2016
3. Deakin CD, Nolan JP, Soar J, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 4. Adult advanced life support. Resuscitation 2010;81:1305–52.
Keywords: opioids, toxicology (PubMed Search)
The pattern of prescription drug abuse continues to center around semisynthetic opioids like oxycodone and hydrocodone. Federal regulations have now raised hydrocodone to a schedule II drug like oxycodone. Despite efforts, the slope for natural and semisynthetic opioids remains steep. The ED measures of education, limit prescriptions for acute pain, minimize number of days/pills prescribed and utlize the prescription drug monitoring program are some basics that can assist you in better prescribing habits.
NCHS Data Brief, Number 166, September 2014
Category: Critical Care
Keywords: peri-Intubation, shock index (PubMed Search)
Identifying patients at risk of hypotension during intubation is not always straight forward. The prevalence of peri-intubation hypotension in the Emergency Department has been demonstrated to be approximately 20%.1 And while certain variables increase the likelihood of peri-intubation hypotension (ex. Shock index> 0.80), no single factor predicts it accurately enough to be used at the bedside.2 In the majority of patients undergoing intubation, clinicians should be prepared for peri-intubation hypotension with either vasopressor infusions or push dose pressors.
1. Heffner AC, Swords D, Kline JA, Jones AE. The frequency and significance of postintubation hypotension during emergency airway management. J Crit Care. 2012;27(4):417.e9-13.
2. Heffner AC, Swords DS, Nussbaum ML, Kline JA, Jones AE. Predictors of the complication of postintubation hypotension during emergency airway management. J Crit Care. 2012;27(6):587-93.
Keywords: vaping (PubMed Search)
Vaping. is the use of electronic device to heat a liuid to generate an aersol or vapor to inhale. The lqiud usually contains nicotine, propylene gylcol, gylcerine, and flavoring. E cigarettes are popular for various reasons simulate tobacco use, odorless, believed to be healthier than tobacco, circumvent no smoking laws, delivery system for cannabinoids. The JUUL, is a sleekly designed e-cigarette which resembles a a USB drive and is increasingly being used by youth and young adults.
Although e-cigarettes cause less health effects than tobacco, current evidence indicates that they are not without risk.
Keywords: hydrofluoric acid, burn, chemical burn, HFA, calcium gluconate (PubMed Search)
Hydrofluoric acid is a weak acid used primarily in industrial applications for glass etching and metal cleaning/plating. It is contained in home rust removers. Although technically a weak acid, it is very dangerous and burns can be subtle in appearance while having severe consequences.
Wilkes G. Hydrofluoric Acid Burns. Jan 28, 2010.
*Extracted from emedicine article.
Wilkes G. Hydrofluoric Acid Burns. Jan 28, 2010.
Category: Visual Diagnosis
50 year-old male with cough and dyspnea. What's the diagnosis?
Here's your answer: http://www.youtube.com/watch?v=Z4yxqRoKX04&feature=youtu.be
Follow me on Twitter (@criticalcarenow) or Google+ (+criticalcarenow)
Keywords: D-Dimer, Pregnancy (PubMed Search)
D-Dimer levels are known to be elevated in pregnancy. But how high is too high and can this test be used in the workup of VTE in pregnant patients?
Recent literature indicates that D-dimer levels in each of the three trimesters are approximately 39% higher: 700, 1000, and 1400 ng/dL for each trimester (normal cutoff 500 ng/dL). So, figure out what trimester your patient is in and use the corresponding D-Dimer level for that trimester.
Hernandez J, Hambleton G, Kline JA. D-dimer concentrations in normal pregnancy. Acad Emerg Med 2004;11:526-527
Keywords: non-accidental trauma, clavicle fracture, neonate, pediatrics, abuse (PubMed Search)
Q: What is wrong with this baby? And what Dx should you entertain?
Previously healthy 7d old presents after difficulty feeding, one episode of vomiting and now with intermittent apneic episodes.
Non-accidental trauma (NAT) is most prevalent in children 0-3 months of age.
Radiographically classic metaphyseal lesions, rib fractures, and multiple fractures in various stages of healing are most commonly described in child abuse cases.
How do we know this is not just birth trauma from a shoulder dystocia, LGA (large for gestational age), or difficult vaginal delivery?
The key is dating the fracture. In this recent publication by Walters MM et al, prior to 8 days of life, 100% of radiographs did NOT have callus present. Callus formation is highly unlikely in fractures less than 9 days old, and typically appears by 15 days old. Callus thickness decreases inversely with fracture age. Additionally, subperiosteal new bone formation is highly unlikely in fractures less than 7 days old and typically appears by 10 days old. Subperiosteal new bone formation increases in thickness inversely with fracture age. Therefore, a clavicle fracture in a 7 day old without subperiosteal new bone formation or callus is unlikely from birth trauma and NAT should be considered.
How can you tell if subperiosteal new bone formation is present?
Subperiosteal new bone formation appears as a hazy cortical margin or a thin layer of bone separated from the original cortex by a discrete lucent interval. The new bone increases in thickness with time and may evolve to appear as a lamellated or multilayered linear hyperdensity parallel to the cortex of the bone. See referenced article for great picture examples.
CT head without contrast if ≤2 yo
Skeletal Survey if ≤ 2 yo
AST, ALT, amylase, lipase, CBC, Manual Differential, BMP, UA, Urine Toxicology
Consults: Ophthalmology, Social Work, Child Protection
OH BUTT TUBE (Dark Green Top Sodium Heparin) for further inpatient team studies
Guided by history, however consider the following:
Full sepsis evaluation for neonate <30 days
Possible reflux or seizure evaluation
Consider NAT or Pertussis/RSV with cyanosis
It is controversial to send these infants home from the ED. Typically they benefit from 24 hours of monitoring, but this is a pearl for another day.
See article for further pictures of subperiosteal new bone formation:
Walters MM, Forbes PW, Buonomo C, and Kleinman PK. Healing Patterns of Clavicular Birth Injuries as a guide to fracture dating in cases of possible infant abuse. Pediatric Radiology. October 2014; 44: 1224-1229.