UMEM Educational Pearls

Category: Airway Management

Title: Flush-Rate O2 for Preoxygenation prior to RSI

Keywords: RSI, Preoxygenation (PubMed Search)

Posted: 9/13/2016 by Rory Spiegel, MD (Emailed: 2/27/2020)
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During rapid sequence intubation (RSI) we endeavor to avoid positive pressure ventilation, prior to securing a definitive airway. As such, an adequate buffer of oxygen is necessary to ensure a safe apneic period. This process involves replacing the residual nitrogen in the lung with oxygen. It has been demonstrated that a standard nonrebreather (NRB) mask alone does not provide a high enough fractional concentration of oxygen (FiO2) to optimally denitrogenate the lungs (1). Even when a nasal cannula at 15L/min is utilized in addition to the NRB, the resulting FiO2 is not ideal. A bag-valve mask (BVM) with a one-way-valve or PEEP valve has been demonstrated to provide oxygen concentrations close to that of an anesthesia circuit. But its effectiveness is drastically reduced if a proper mask seal is not maintained during the entire pre-oxygenation period (1). This is not always logistically possible in the chaos of an Emergency Department intubation.

A standard NRB with the addition of flush-rate oxygen appears to be a viable alternative. Recently published in Annals of Emergency Medicine, Driver et al demonstrated that a NRB with wall oxygen flow rates increased to maximum levels, rather than the standard 15L/min, provided end-tidal O2 (ET-O2) levels similar to an anesthesia circuit (2). 

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Category: Critical Care

Title: Utilization of the Mechanical Ventilator in Cardiac Arrest

Keywords: CPR, Cardiac Arrest (PubMed Search)

Posted: 11/15/2016 by Rory Spiegel, MD (Emailed: 2/27/2020)
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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).

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Category: Critical Care

Title:

Keywords: amikacin, Torsades de pointes, QT prolongation (PubMed Search)

Posted: 8/20/2019 by Quincy Tran, MD (Emailed: 2/27/2020)
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Torsades de pointes and QT prolongation Associated with Antibiotics

 

Methods

The authors queried the United States FDA Adverse Event Reporting System (FAERS) from 01/01/2015 to 12/31/2017 for reports of Torsade de points/QT prolongation (TdP/QT).

Reporting Odd Ratio (ROR) was calculated as the ratio of the odds of reporting TdP/QTP versus all other ADRs for a given drug, compared with these reporting odds for all other drugs present in FAERS

Results

FAERS contained 2,042,801 reports from January 1, 2015 to December 31, 2017. There were 3,960 TdP/QTP reports from the study period (0.19%).

 

Macrolides               ROR 14 (95% CI 11.8-17.38)

Linezolid                  ROR 12 (95% CI 8.5-18)

Amikacin                 ROR 11.8 (5.57-24.97)

Imipenem-cilastatin ROR 6.6 (3.13-13.9)

Fluoroquinolones   ROR 5.68 (95% CI 4.78-6.76)

 

Limitations:

These adverse events are voluntary reports

There might be other confounded by concomitant drugs such as ondansetron, azole anti-fungals, antipsychotics.

 

Bottom Line:

This study confimed the previously-known antibiotics to be associated with Torsades de pointes and QT prolongation (Macrolides, Linezolid, Imipenem and Fluoroquinolones). However, this study  found new association between amikacin and Torsades de pointes/QT prolongation.

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Category: Toxicology

Title: Opioid Prescription Drug Abuse - The Pattern of Abuse

Keywords: opioids, toxicology (PubMed Search)

Posted: 11/20/2014 by Fermin Barrueto, MD (Emailed: 2/27/2020) (Updated: 2/27/2020)
Click here to contact Fermin Barrueto, MD

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.

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Category: Toxicology

Title: Opioid Prescription Drug Abuse - The Pattern of Abuse

Keywords: opioids, toxicology (PubMed Search)

Posted: 11/20/2014 by Fermin Barrueto, MD (Emailed: 2/27/2020) (Updated: 2/27/2020)
Click here to contact Fermin Barrueto, MD

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.

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Category: Orthopedics

Title: Sports Hernia/Athletic pubalgia

Keywords: Sports Hernia, groin pain (PubMed Search)

Posted: 4/6/2014 by Brian Corwell, MD (Emailed: 2/27/2020)
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Sports Hernia/Athletic pubalgia

 

Hx: Gradually increasing lower abdominal/proximal adductor pain. Usually activity related, resolves with rest. Frequent return despite rest when sports activity resumes.

Most common in athletes who perform cutting/maneuvers in addition to frequent acceleration/deceleration. Think ice hockey and soccer.

Bilateral symptoms not uncommon.

PE:  Resisted sit up with palpation of the inferolateral edge of the distal rectus may recreate symptoms. Similarly, resisted hip adduction may elicit symptoms. 

If for no other reason than to make the diagnosis harder to make, valsalva induced pain may also occur.

Fluoroscopic guided injections can be helpful to isolate the site of pain generation.

First line therapy is rest, non-narcotic analgesia and physical therapy.

With surgery, >80% return to pre injury level of play.

 

http://atlantasportsmedicine.com/orthopedic-surgeon/wp-content/uploads/2009/11/groin-injuries.jpg

 

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Category: Critical Care

Title:

Keywords: Right Ventricle, RV Size (PubMed Search)

Posted: 11/5/2019 by Kim Boswell, MD (Emailed: 2/27/2020)
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Rapid Assessment of the RV on Bedside Echo

There are several causes of acute RV dysfunction resulting in a patient presenting to the ER with unstable hemodynamics. Some of these include acute cor pulmonale, acute right sided myocardial infarction and acute submassive or massive pulmonary embolism. While bedside assessment of the LV function is often performed by the ED physician, simultaneous evaluation of the RV can provide crucial information that can help guide therapeutic decisions to prevent worsening of the patient’s clinical condition. A rough guideline to determine RV size and function is below using the apical 4 chamber view.

Normal RV size :            <2/3 the size of the LV

Mildly enlarged RV :       >2/3 the size of the LV, but not equal in size

Moderately enlarged RV:  RV size = LV size

Severely enlarged RV:      RV size > LV size

Patients who are found to have RV dilation should be given fluids in a judicious fashion as the RV is not tolerant of fluid overload. Early diagnosis of the cause of acute RV failure should be sought to guide definitive therapy, but early institution of inotropic support should be considered. Frequent reassessments of biventricular function during resuscitation should be performed.

 

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Attachments

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Category: Neurology

Title: Phantoms in EMS

Keywords: Stroke, EMS, prehospital care, tPA, emergency medical services, fibrinolysis (PubMed Search)

Posted: 5/15/2014 by Ben Lawner, DO (Emailed: 2/27/2020) (Updated: 7/3/2014)
Click here to contact Ben Lawner, DO

The Prehospital Acute Neurological Treatment and Optimization of Medical Care in Stroke Study (PHANTOM-S) was a randomized prehospital  clinical trial. On certain days, a dedicated Stroke Emergency Mobile (STEMO) responded to possible ischemic stroke incidents. Outcomes measured included time to thrombolysis and adverse events such as intracerebral hemorrhage. As opposed to usual prehospital care, a STEMO ambulance was equipped with a CT scanner, point of care laboratory, and a neurologist. According to the study, STEMO use resulted in reduced time to treatment (tPA) without adverse events. 

Though this trial did not specifically measure clinical endpoints, it addresses issues central to the delivery of specialized prehospital care:

1) Are there certain conditions which might warrant a tailored, super-specialized EMS response?
2) Are EMS systems capable of delivering definitive care to the patient as opposed to delivering the patient to definitive care? 

Stateside study has already started.  The Houston Fire Department, in partnership with UTHeath, has already loosed a "Mobile Stroke Unit" on the streets. Like the STEMO, the specialized ambulance will be University hospital based, carry a neurologist, and have the capability to administer tPA. 

STEMO pictures courtesy of the "NeuroEMS Blog"
http://www.neuroems.com/2014/05/14/tpa-in-the-truck-results-of-the-phantom-s-trial/

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Category: Critical Care

Title: Predicting peri-Intubation hypotension

Keywords: peri-Intubation, shock index (PubMed Search)

Posted: 2/7/2017 by Rory Spiegel, MD (Emailed: 2/27/2020)
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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.

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Category: Toxicology

Title: Hydrofluoric Acid Burns

Keywords: hydrofluoric acid, burn, chemical burn, HFA, calcium gluconate (PubMed Search)

Posted: 9/5/2010 by Dan Lemkin, MD (Emailed: 2/27/2020) (Updated: 10/2/2010)
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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.

Hydrofluoric acid burn

Wilkes G. Hydrofluoric Acid Burns. Jan 28, 2010. 
http://emedicine.medscape.com/article/773304-overview

  • 2 mechanisms that cause tissue damage*
    • corrosive burn from the free hydrogen ions
    • chemical burn from tissue penetration of the fluoride ions
  • Clinical features*
    • Cutaneous burns - absent findings to white-blue appearance
    • Pulmonary edema
    • Hypocalcemia, hyperkalemia, hypomagnesemia
  • Treatment*
    • Decontaminate by irrigation with copious amounts of water.
    • With any evidence of hypocalcemia, immediately administer 10% calcium gluconate IV.
    • Cutaneous burns:
      • Apply 2.5% calcium gluconate gel to the affected area. If the proprietary gel is not available, constitute by dissolving 10% calcium gluconate solution in 3 times the volume of a water-soluble lubricant (eg, KY gel). For burns to the fingers, retain gel in a latex glove.
      • If pain persists for more than 30 minutes after application of calcium gluconate gel, further treatment is required. Subcutaneous infiltration of calcium gluconate is recommended at a dose of 0.5 mL of a 5% solution per square centimeter of surface burn extending 0.5 cm beyond the margin of involved tissue (10% calcium gluconate solution can be irritating to the tissue).
        • Do not use the chloride salt because it is an irritant and may cause tissue damage.

*Extracted from emedicine article.

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Category: Vascular

Title: D-Dimer in Pregnancy

Keywords: D-Dimer, Pregnancy (PubMed Search)

Posted: 7/9/2008 by Rob Rogers, MD (Emailed: 2/27/2020) (Updated: 2/27/2020)
Click here to contact Rob Rogers, MD

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.

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Category: Orthopedics

Title: Fulcrum test

Posted: 10/1/2017 by Brian Corwell, MD (Emailed: 2/27/2020) (Updated: 2/27/2020)
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https://www.physio-pedia.com/Fulcrum_Test


Category: Orthopedics

Title: Morel-Lavall e lesion

Posted: 10/1/2017 by Brian Corwell, MD (Emailed: 2/27/2020) (Updated: 2/27/2020)
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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4126145/