Category: Critical Care
Keywords: conservative oxygenation (PubMed Search)
This study’s results differed from previous single center study (Girardis JAMA 2016) or meta analysis (Chu DK, Lancer 2018), which showed mortality benefit in patients with conservative oxygen (Girardis & Chu) and more ventilator-free days (Girardis).
Conclusion: Conservative oxygen did not significantly affect the ventilator free days of mechanically ventilated patients.
1. ICU-ROX Investigators and the Australian and New Zealand Intensive Care Society Clinical Trials Group, Mackle D, Bellomo R, Bailey M, Beasley R, Deane A, Eastwood G, Finfer S, Freebairn R, King V, Linke N, Litton E, McArthur C, McGuinness S, Panwar R, Young P.
Conservative Oxygen Therapy during Mechanical Ventilation in the ICU. N Engl J Med. 2019 Oct 14. doi: 10.1056/NEJMoa1903297. [Epub ahead of print]
2. Chu DK, Kim LH, Young PJ, et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis.
Lancet 2018; 391: 1693-705.
3. Girardis M, Busani S, Damiani E, et al. Effect of conservative vs conventional oxygen therapy on mortality among patients in an intensive care unit: the Oxygen-ICU. randomized clinical trial.
JAMA 2016; 316: 1583-9.
Category: Visual Diagnosis
A ~55 year-old female with a history of ESRD and diabetes who presented to the ED with progressively worsening foot odor. An x-ray was performed. The picture below shows the right foot.
What is the diagnosis?
Necrotizing infection of the foot
Yaghoubian et al. Use of admission serum lactate and sodium levels to predict mortality in necrotizing soft-tissue infections. Archives of surgery. 2007.
Anaya DA and Dellinger EP. Necrotizing soft-tissue infection: diagnosis and management. Clinical infectious diseases. 2007.
Keywords: back pain, muscle relaxants (PubMed Search)
The role of skeletal muscle relaxants in the management of lower back pain in the ED
Patients with lower back pain (LBP) presenting to the ED are often treated with NSAIDs plus skeletal muscle relaxants.
A recent study in Annals of Emergency Medicine compared functional outcomes and pain in ED patients with acute non radicular LBP with 4 different treatment regimens.
Conclusion: Adding a muscle relaxant to ibuprofen did not improve pain or improve function at 1 week following an ED visit for LBP.
Note: Prior studies have found no benefit to adding opioids or diazepam to NSAIDs for ED patients with acute non radicular LBP
Friedman et al., 2019. Annals of Emergency Medicine
Keywords: EVALI, e-cigarette, vaping, lung injury (PubMed Search)
As of November 20, 2019:
2290 cases of e-cigarette, or vaping, product use-associated lung injury (EVALI) from 49 states (except Alaska), District of Columbia and 2 U.S. territories.
Analysis of 29 bronchoalveolar lavage (BAL) fluid samples from EVALI patients submitted to CDC from 10 states showed:
*** Vitamin E acetate appears to be associated with EVALI but the investigation is continuing.***
Some research has suggested that oral vitamin E use has potential beneficial effects (i.e. anti-inflammatory/antioxidant) in the lung (e.g. asthma and allergic lung disease), cardiovascular disease and prostate cancer (Cook-Mills JM et al. 2013; Jiang Q et al. 2001)
Common uses of vitamin E
There is limited to no data on pulmonary effect of vitamin E from inhalation in the scientific literature.
Stay tuned for additional updates from CDC.
Keywords: geriatrics, orthopaedic, fractur (PubMed Search)
Therefore, pain medications must be dosed carefully, which runs the risk of underdosing. Pain medications can also contribute to delerium, and decreased functional status.
Keywords: Sore throat, strep throat (PubMed Search)
Streptococcal pharyngitis is common in the pediatric population however in children younger than 3 years, group A streptococcus (GAS) is a rare cause of sore throat and sequela including acute rheumatic fever are very rare. Inappropriate testing leads to increased healthcare and unnecessary exposure to antibiotics.
The national guidelines published by the Infectious Diseases Society of America do NOT recommend GAS testing in children less than the age of 3 years unless the patient meets clinical criteria and has a home contact with documented GAS.
Ahluwalia et al. Reducing streptococcal testing in patients less than 3 years old in an emergency department. Pediatrics 2019;144:4.
Keywords: meformin overdose, metformin associated lactic acidosis, observation period (PubMed Search)
Metformin is one of the most commonly prescribed oral hypoglycemic agents. Metformin associated lactic acidosis (MALA) is uncommon but potentially life-threatening complication of metformin overdose.
Lactic acidosis occurs due to inhibition of mitochondrial glycerophosphate dehydrogenase, resulting in decreased conversion of lactic acid to pyruvate.
A small retrospective study (using Illinois Poison Center data) attempted to characterize the development of MALA after an acute overdose.
MALA was defined as
40 cases of MALA identified between Jan. 2001 to Dec. 2014
Time to development of MALA (n=30)
Death: 1 (2.5%)
Jillian Theobald, Jamie Schneider, Navneet Cheema & Carol DesLauriers (2019) "Time to development of metformin-associated lactic acidosis," Clinical Toxicology, DOI: 10.1080/15563650.2019.1686514
Category: Critical Care
Keywords: OHCA, cardiac arrest, resuscitation, PEA, pesudo-PEA, pulseless electrical activity (PubMed Search)
When managing cardiac arrest, it is important to differentiate PEA, the presence of organized electrical activity without a pulse, from "pseudo-PEA,"where there is no pulse but there IS cardiac activity visualized on ultrasound.
Bottom Line: Pseudo-PEA is different from PEA. Utilize POCUS during your cardiac arrests to identify it and to help diagnose reversible causes, and treat it as a profound shock state with the appropriate supportive measures, i.e. pressors or inotropy.
Rabjohns J, Quan T, Boniface K, Pourmand A. Pseudo-pulseless electrical activity in the emergency department, an evidence based approach. Am J Emerg Med. 2019. DOI:https://doi.org/10.1016/j.ajem.2019.158503
Keywords: Hip pain, bursitis (PubMed Search)
Lateral hip pain is a common presentation of hip pain.
Typically seen in runners and women over the age of 40 who start unaccustomed exercise.
Pain from OA of the hip which is typically medial (groin pain)
Lateral hip pain has traditionally been diagnosed at trochanteric bursitis.
Research suggests that lateral hip pain may be multifactorial and better termed Greater trochanteric pain syndrome.
Pain from the gluteal medius and/or minimus due to non-inflammatory tendonopathy is likely causative. This may cause a secondary bursitis.
Pain is insidious, gradual worsens and is variable based on activity type.
Also, can be seen after a fall resulting in tearing.
Pain is described as a deep ache or bruise. It can stay localized or radiate down lateral thigh towards knee.
Patients report night/early morning pain and when rolling over onto the outer hip on affected side.
Fatigue from prolonged sitting, walking and single leg loading activities such as walking up stairs.
Provoking activities and postures cause compressive forces on the involved tendons.
These generally occur when the hip is adducted across midline such as with
Place pillow between legs to align pelvis and keep knee and hip in line
Crossed leg sitting
Sit w/ knees at hip distance and feet on floor
Selfie poses - Standing w a hitched hip (pushing hip to the side).
Attempt to correct biomechanical issues before progressing directly to bursal steroid injection
May only be a temporary fix if underlying issue not addressed.
A helpful clinical guide
Keywords: droperidol, cannabinoid hyperemesis syndrome, recurrent nausea/vomiting (PubMed Search)
Droperidol has recently become available again in select U.S. institutions. It has been used as an antiemetic and to treat agitation prior to the FDA’s black box warning (for QT prolongation) and national shortage.
Recently, a retrospective study was conducted (Melbourne, Australia) in the use of droperidol in the management of cannabinoid hyperemesis syndrome (CHS).
689 medical records were identified from January 2006 to December 2016.
76 cases met diagnostic criteria of CHS (below)
Droperidol group (DG) = 37; no droperidol group (NDG)= 39
Median length of stay:
Median time to discharge after final drug administration:
Frequency of droperidol (dose) used:
Metoclopramide and Ondansetron use in non-droperidol group was twice that of droperidol group
Category: Pharmacology & Therapeutics
Keywords: Phenytoin, Fosphenytoin (PubMed Search)
Phenytoin can be a complex medication. There are different levels than can be ordered, adjustments based on albumin, various pharmacokinetic equations, and multiple formulations. Below are the simplified answers to some of the most common questions (see in-depth section for explanations):
Which phenytoin level (free or total) do I order?
Total Phenytoin Level.
What do I do after the level results?
Undetectable Level: Load patient with 20 mg/kg of total body weight (max dose 1,500 mg).
Subtherapeutic Level (<10 mcg/mL): Calculate an approximate loading dose using this equation….Phenytoin Dose (mg)=(15-measured total level)*(0.7*patient weight).
Therapeutic Level (10-20 mcg/mL): Add an additional agent.
Supratherapetutic/Toxic Level (>20 mcg/mL): Contact Poison Center (1-800-222-1222).
What formulation do I order for loading?
IV: Use fosphenytoin.
PO: Any formulation will work. Give as a single loading dose or, if concerned for GI upset, give in 2-3 divided doses separated by 2 hours.
***Disclaimer: These answers are simplified for the initial management of most patients in the ED. More complex answers may be required in some situations.***
Which phenytoin level (free or total) do I order?
Total Phenytoin Level
Free and total phenytoin levels are available at most institutions. Free levels are more predictive of efficacy and toxicity; however, free levels are tested only at certain times at most institutions which can lead to a delay in results. Total phenytoin levels are a good approximation of therapeutic levels and are easier to perform pharmacokinetic caculations.
What do I do after the level results?
Undetectable Level: Load patient with 20 mg/kg of total body weight (max dose 1,500 mg)
For phenytoin naive or noncompliant patients that present with an undetectable level, the guideline recommended loading dose is phenytoing 20 mg/kg.
Subtherapeutic Level (<10 mcg/mL): Calculate an approximate loading dose using this equation….Phenytoin Dose (mg)=(15-measured total level)*(0.7*patient weight)
Phenytoin has many complex equations related to the pharmacokinetics of the medication. There are adjustments for albumin, approximations of free/total levels, estimations of loading doses, etc. A simple PK equation that can be applied to most medications is concentration=(dose*salt factor)/(volume of distribution). For application to clinical cases with phenytoin this equation can be manipulated to yield the dose=(desired concentration-measured concentration)*(population Vd*patient weight).
For the equation given to you above, this equation has modified. The equation was manipulated to solve for dose. The salt correction factor was removed. For phenytoin the salt correction factor is 0.92, thus removing it does not significantly affect the results. There are also two variables of the equation that are prepopulated. Therapeutic levels of phosphenytoin are 10-20 mcg/mL. A simplified desired concentration is to aim for the middle concentration of 15 mcg/mL. The population Vd is a range; however, we use 0.7 L/kg for ease of caculations.
Therapeutic Level (10-20 mcg/mL): Add an additional agent
There is no therapeutic benefit to giving additional phenytoin in these patients. Phenytoin has complex pharmacokinetics and giving patient additional phenytoin will likely lead to phenytoin toxicity.
Supratherapetutic/Toxic Level (>20 mcg/mL): Contact Poison Center (1-800-222-1222)
Experts in toxicology are available 24/7 to assist in the managment of patients with phenytoin toxicity.
What formulation do I order for loading?
IV: Use fosphenytoin
For initial IV loading, fosphenytoin (a prodrug of phenytoin) is preferred. Compared to phenytoin, fosphenytoin can be administer faster, has less side effects, and does not require a filter for administration; making fosphenytoin the preferred product. Fosphenytoin is doses in phenytoin equivalents (PE) to prevent confusion with dosing.
PO: Any formulation will work. Give as a single loading dose or, if concerned for GI upset, give in divided doses separated by 2 hours.
Any oral formulation of phenytoin (immediate release, extended release, oral solution) is appropriate for oral loading of phenytoin. There is evidence supporting a single oral loading dose of phenytoin can be tolerated; however, due to historical guidance of limiting the oral dose to <400 mg and separating doses by 2 hours due to concern for absorption and potential for GI upset some providers may find a single dose controversial. An alternative method is to divide the total phenytoin dose into 2-3 doses and administer separated by 2 hours for each dose.
1. Abernethy DR, Greenblatt DJ. Phenytoin disposition in obesity. Determination of loading dose. Arch Neurol. 1985;42(5):468-71.
2. Anderson GD, Pak C, Doane KW, et al. Revised Winter-Tozer equation for normalized phenytoin concentrations in trauma and elderly patients with hypoalbuminemia. Ann Pharmacother. 1997;31(3):279-84.
3, Glauser T, Shinnar S, Gloss D, et al. Evidence-Based Guideline: Treatment of Convulsive Status Epilepticus in Children and Adults: Report of the Guideline Committee of the American Epilepsy Society. Epilepsy Curr. 2016;16(1):48–61. doi:10.5698/1535-7597-16.1.48
4. Kane SP, Bress AP, Tesoro EP. Characterization of unbound phenytoin concentrations in neurointensive care unit patients using a revised Winter-Tozer equation. Ann Pharmacother. 2013;47(5):628-36.
5. Osborn HH, Zisfein J, Sparano R. Single-dose oral phenytoin loading. Ann Emerg Med. 1987;16(4):407-12.
6. Ratanakorn D, Kaojarern S, Phuapradit P, Mokkhavesa C. Single oral loading dose of phenytoin: a pharmacokinetics study. J Neurol Sci. 1997;147(1):89-92.
7. Soriano VV, Tesoro EP, Kane SP. Characterization of Free Phenytoin Concentrations in End-Stage Renal Disease Using the Winter-Tozer Equation. Ann Pharmacother. 2017 May 1.
8. Winter MG, Tozer TN. Chapter 25. Phenytoin. In: Evans WE, Schentag JJ, Jusko WJ. Applied pharmacokinetics: principles of therapeutic drug monitoring. 3rd ed. Vancouver, WA: Applied Therapeutics, 1992:1-44.
Category: Critical Care
Keywords: Pseudo-PEA, Shock, Resuscitation (PubMed Search)
Ever been in an acute rescucitation and found yourself unable to remember all of those famous ACLS Hs and Ts? I know I have. A few years ago Littman et al published an alternative approach to critically ill, hypotensive medical patients with non shockable rhythms. Unfortunately, it seems like some of the enthusiasm for this approach has died down, but I still think it's something you're more likely to recall in a pinch than the Hs and Ts and is a better way of getting started with a hypotensive non-trauma patient. And it's so simple you may actually remember it!
1) Look at the monitor. Is the rhythm narrow or wide?
2a) Narrow - more likely a mechanical problem (tamponade, tension PTX, autoPEEP, or PE). Give IVF and search for one of these causes (and correct it!). Keep in mind that ultrasound can help you differentiate a lot of these.
2b) Wide - more likely a metabolic problem (hyperK, sodium channel blockade, etc*). Give empiric calcium, bicarb, and other therapies targeted for these problems (if desired) and get stat labs.
Take a minute and either go to this REBEL EM post:
To review this, or look at the attached diagrams.
*Dr. Mattu would want me to remind you that hyperkalemia IS a sodium channel poisoned state, so there's no need to think of these two separately
Littmann et al. A Simplified And Structured Teaching Tool for the Evaluation and Management of Pulseless Electrical Activity. Med Princ Pract 2014; 23: 1 – 6. PMID: 23949188
Keywords: Concussion Incidence, epidemiology, (PubMed Search)
A recent epidemiology study in Pediatrics looked at concussions in 20 high school sports during the 2013–2014 to 2017–2018 school years.
For every athlete, one practice or competition was counted as one exposure.
Overall, 9542 concussions were reported for an overall rate of 4.17 per 10 000 athletic exposures (AEs).
Football continues to have the highest incidence with a concussion rate of 10.40 per 10 000 AEs.
As in previous studies, rates in competition (33.19 to 39.07 per 10 000 AEs) are increasing and higher than rates in practice which are lower and decreasing over the study period (5.47 to 4.44 per 10 000 AEs).
This may reflect better reporting or increasing injury rate
In all 20 sports, recurrent concussion rates decreased from 0.47 to 0.28 per 10 000 AEs.
Confirming prior studies, among sex-comparable sports, concussion rates were higher in girls than in boys (3.35 vs 1.51 per 10 000 AEs).
Also, among sex-comparable sports, girls had larger proportions of concussions that were recurrent than boys (9.3% vs 6.4%).
This study may reflect effective implementation of strategies to reduce concussion incidence such as mandatory removal from play and more stringent requirements associated with return to play.
Concussion Incidence and Trends in 20 High School Sports, Kerr et al., 2019, Pediatrics.
Keywords: lactated ringer, LR, normal saline, NS (PubMed Search)
Bottom line: Balance fluid resuscitation with LR was not associated with improved outcomes compared to NS and pediatric sepsis. Selective LR use necessitates a prospective trial to definitively determine comparative effects among crystalloids.
1. Weiss SL, Keele L, Balanmuth F, Vendetti N, Ross R, Fitzgerald JC, Gerber JS. Crystalloid Fluid Choice and Clinical Outcomes in Pediatric Sepsis: A Matched Retrospective Cohort Study. J Pdatr.207 Mar:182:304-310.
2. Balamuth F, Kittick M, McBride P, Woodford AL, Vestal N, Casper TC, Metheney M, Smith K, Atkin NJ, Baren JM, Dean JM, Kuppermann N, Weiss SL. Pragmatic Pediatric Trial of Balanced versus Normal Saline Fluid in Sepsis: The PRoMPT BOLUS Randomized Controlled Trial Pilot Feasibility Study. Acad Emerg Med. 2019 Jun 10
Keywords: VA-ECMO, drug-induced cardiogenic shock (PubMed Search)
Patients with drug-induced cardiogenic shock [DIC] (e.g. overdose of CCB/BB, membrane stabilizing agents, etc.) are often managed with medical interventions such as vasopressors, bicarbonate infusion, high-dose insulin, lipid emulsion therapy. A fraction of these patients may be refractory to the standard medical therapy. VA-ECMO (venoarterial extracorporeal membrane oxygenation) has been utilized in such situation; yet clinical experience of using VA-ECMO in DIC is limited.
A recent retrospective study of the Extracorporeal Life Support Organization’s ECMO registry showed
Clinical utility of venoarterial-extracorporeal membrane oxygenation (VA-ECMO) in patients with drug-induced cardiogenic shock: a retrospective study of the Extracorporeal Life Support Organizations’ ECMO case registry
Keywords: Cryptococcus neoformans, cryptococcosis, meningoencephalitis (PubMed Search)
Bottom Line: Consider cryptococcal meningitis even in immunocompetent patients.
Category: Airway Management
Keywords: PE, tachypnea, Critical Care, ED Disposition (PubMed Search)
ICU admission rates for all acute PEs vary wildly across the country (<5% to ~80%).
To predict which hemodynamically stable, normotensive PE patients should be admitted to the ICU, a single-center retrospective analysis of 7 years’ data sought to describe the reasons why normotensive patients with PE required vasopressors within 48 hours of admission to the ICU. The authors studied 293 patients admitted to the ICU at Beth Israel Deaconess in Boston and found only 8 patients (2.7%) who decompensated within the first 2 days. Of MANY variables studied, only respiratory rate was significantly different between those who decompensated and those who did not (mean RR 29 with range 26-32 in the decompensated group vs mean 21 with range 17-24).
Bottom Line: cost control experts may lean on you to admit fewer PE patients to the ICU. There is no perfectly reliable way to predict which normotensive patient with a PE will decompensate. The PESI score has been validated but even the low risk cohort had 1.6% mortality at 3 days. The BOVA score has been validated but its endpoint of mortality at 30 days is less useful for planning admission. Tachypnea should concern you.
Admon A, Seymour C, Gershengorn H, et al. Hospital-level variation in ICU admission and critical care procedures for patients hospitalized for pulmonary embolism. Chest 2014; 146(6):1452-1461
Patel H, Shih J, Gardner R, et al. Hemodynamic decompensation in normotensive patients admitted to the ICU with pulmonary embolism. Journal of Critical Care 2019; 54:105-109
Keywords: sedation, autism spectrum disorder (PubMed Search)
Brown et al. Procedural sedation in children with autism spectrum disorders in the emergency department. Am J Emerg Med. 2019 Aug;37(8):1404-1408.
Category: Critical Care
The Critically Ill Geriatric Patient with Sepsis
Khoujah D, et al. Resuscitating the critically ill geriatric emergency department patient. Emerg Med Clin N Am. 2019; 569-81.
Keywords: Playing surface, concussion (PubMed Search)
Synthetic turf playing surfaces have been growing in popularity over the last decade and seem to have become a new standard.
Due to the need for durable fields that can accommodate multiple teams/activities, in addition to the high cost of maintaining grass and the need to conserve water, many parks and schools have switched from grass to turf. Turf is advertised as maintenance free but ….this is not the case.
Locally, at M&T Bank Stadium, groundskeepers drive a LitterKat turf sweeper across the field for 4 hours 2-3 times a week to ensure that the synthetic rubber is cleaned and distributed evenly. The field is also repainted every 4 games because the paint may become hard. The cost of this level of maintenance is beyond what many parks and local high schools can afford.
A recent study examined high school concussion data at almost 2000 high schools with over 14,000 recorded concussions. Researchers concluded that more concussions occurred in games than practices. Interestingly, they also found that playing surface was significantly associated with concussion. Almost 90% of all injuries occurred on turf-based surfaces. Turf outweighed all other mechanisms of injury, including helmet-to-helmet hits and grass playing surface. Between 10 and 15.5% of concussions occur from helmet to ground contact. In the NFL, this mechanism accounts for about 1 in 7 concussions.
Attempting to limit total exposure time in practice and games on turf surfaces may be beneficial until more study is needed.