Keywords: PPI, Gi bleed (PubMed Search)
Continuous vs intermittent dosing of PPIs in bleeding peptic ulcer disease
There continues to be debate as to the optimal dose, frequency, and route of proton pump inhibitors (PPIs) in bleeding ulcers, especially prior to endoscopy. Multiple guidelines including from the American Journal of Gastroenterology continue to recommend continuous dosing of PPIs.1,2,3 However, multiple studies appear to show at least non-inferiority when compared with intermittent dosing of PPIs.
The most frequently cited study for non-inferiority is a meta-analysis of 13 randomized control trials by Sachar et al. which evaluated PPI use in patients presenting with upper GI bleeds who were endoscopically found to have a bleeding gastric or duodenal ulcer with high risk features (active bleeding, non-bleeding visible vessel, or adherent clot)4. There was non-inferiority of intermittent dosing in rebleeding, need for repeat endoscopy/surgery, RBC transfusions, and mortality with a non-statistically significant trend towards superiority of intermittent dosing.
However, the patients were only randomized to continuous vs intermittent dosing AFTER endoscopic treatment. In addition, the dosing regimen of intermittent dosing was quite variable.
Keywords: Asthma, chest xray (PubMed Search)
Chest xrays (CXRs) may lead to longer length of stay, increased cost, unnecessary radiation exposure, and inappropriate antibiotic use.
CXR in asthma are indicated for:
-severe persistent respiratory distress, room air saturations <91%
- focal findings (localized rales, crackles, decreased breath sounds with or without a documented fever > 38.3) not improving on >11 hours of standard asthma therapy
- concern for pneumomediastinum or pneumothorax
This study tried to use quality improvement measures to decrease the rate of chest xrays in children seen for asthma.
6680 children with billing codes for asthma had 1359 CXRs. Using a clinical practice guideline and then targeted intervention, the group was able to reduce CXR use from 29% to 16%. In subgroup analysis, the CXR use decreased from 21.3% to 12.5% for discharged patients and 53.5% to 31.1% for admitted patients.
The National Asthma Education and Prevention Program has created guidelines to help providers manage acute asthma exacerbations stating that CXRs should be reserved for patients suspected of having an alternate diagnosis such as pneumothorax, pneumomediastinum or congestive heart failure. This does not include the suspicion for associated pneumonia! A study of >14,000 patients with asthma showed that less than 2% also had pneumonia.
The interventions done in this study were:
An electronic asthma order set was created to include “CXR not routinely recommended”
Clinical practice guidelines were reviewed with residents, faculty, nursing, and respiratory therapy at regular intervals
Copies of the clinical practice guidelines were posted in a highly visualized area
CXRs removed from the default order set
Wheezing was removed as an indication for CXR
CXR in asthma are indicated for: severe persistent respiratory distress, room air saturations <91%, focal findings not improving on >11 hours of standard asthma therapy or concern for pneumomediastinum or pneumothorax
Watnick CS, Arnold DH, Latuska RL, O’Connor M, Johnson DP. Successful Chest Radiograph Reduction by Using Quality Improvement Methodology for Children with Asthma. Pediatrics. Published online July 11, 2018.
Keywords: Sulfonylureas, Octreotide (PubMed Search)
Sulfonylureas are commonly used oral hypoglycemic agents for type II diabetes. Agents on the market include glipizide (Glucotrol), glyburide (Micronase, Glynase, Dibeta) and glymepiride (Amaryl). These agents exert their effect by stimulation of insulin release from the pancreatic beta islet cells. Following overdose, hypoglycemia is usually seen within a few hours of ingestion and can be prolonged and profound. First line treatment for rapid correction of severe hypoglycemia is administration of an intravenous bolus of concentrated dextrose. However, use of dextrose infusion in attempt to maintain euglycemia is problematic as it can cause further release of insulin and rebound hypoglycemia. Octreotide ia a long acting synthetic somatostain analogue, blocks insulin secretion and has been shown to prevent recurrence of hypogylcemia better than placebo.
Comparison of Octreotide and standard therapy versus standard therapy alone for treatment of sulfonylurea-induced hypoglycemia, Fasano CJ, O’Malley, et al. Ann Emerg Med. 2008 Apr;51(4): 400-406.
Octreotide for the treatment of sulfonylurea poisoning. Glatstein M. et al. Clin Toxicol 2012;50:795-804.
Category: Critical Care
Keywords: noninvasive positive pressure ventilation, NIV, NIPPV, DNI, do-not-intubate, palliative care, end-of-life, respiratory distress (PubMed Search)
When a do-not-intubate (DNI) hospice patient arrives in the ED with respiratory distress, consideration of non-invasive positive pressure ventilation (NIPPV) could invoke either a “What other option do I have?” or “Why torture the patient and prolong the dying process?” sentiment.
But what’s the data?
A recently-published meta-analysis1 found that in DNI patients receiving NIPPV, there was a 56% survival rate to hospital discharge and 32% survival to 1-year.
Independent studies have demonstrated:
Keywords: Cervical spine, neuropraxia (PubMed Search)
Stingers and Burners
Also known as transient brachial plexus neuropraxia, “dead arm syndrome,” or brachial plexopathy. Symptoms such as pain, burning, and/or paresthesias in a single upper limb, lasting seconds to minutes.
Usually involves more than one dermatome
May be associated with weakness.
-Common in collision sports that involve tackling, such as football.
-Most common C-spine injury in American Football.
-More than 50% of college football players sustain a stinger each year
-Having 1 stinger increases the risk of having another 3 fold
Mechansims: C5, C6 (deltoid,biceps) most commonly involved
-Traction injury due to forcible lateral neck flexion away with downward displacement of arm
-Nerve root compression during combined neck extension and lateral neck flexion
-Direct trauma to the brachial plexus in the supraclavicular fossa
-Examine muscle strength in the deltoid, biceps, and infraspinatus muscles
-Check sensation and reflexes in upper extremities
-Check C-spine range of motion and perform Spurling’s Test
Consider MRI for symptoms lasting more than 24 hours, bilateral symptoms or for recurrent stingers
Return to play guidelines vary:
-No neurologic symptoms
-Can return to play in same game if symptoms resolve within 15 minutes and no prior stingers that season.
-If 2nd stinger in that season, do NOT return to play in the same game
-if 3rd stinger in a season, consider imaging before return to play and consider sitting out the remainder of the season.
Keywords: Pediatrics, Migraine, Abdominal Migraine, Headache (PubMed Search)
Abdominal pain in children can be just as frustrating as dizzy in the elderly. Your exam is targeted at quickly ruling out acute pathologies, but then what? The diagnosis is often functional gastrointestinal disorders, like the ever exciting constipation. Abdominal migraine (AM) is an additional entity to consider during your emergency department evaluation.
The following factors are often associated with AM:
- peak incidence at 7 years old
- paroxsymal, periumbilical abdominal pain lasting more than 1 hour
- family history of migraine
- episodes not otherwise explained by known pathology.
AM can be associated with headache, pallor, anorexia, photophobia, and fatigue. There are multiple theories on the pathogenesis, which can be found in the article cited below. If there is a known history, and the patient is presenting with an exacerbation, the treatment protocols for migraine headache may be employed with good success.
AM is increasingly recognized as a source of recurrent abdominal pain in children. If other organic pathologies can be ruled out, this may be an important diagnosis to consider so your patient can get the appropriate follow up and outpatient management.
Keywords: antimuscarinic/anticholinergic toxicity, reversal of delirium (PubMed Search)
From 1960s to 1970s, physostigmine was routinely administered as part of the "coma cocktail." Since the publication of two cases by Pentel (1980) that resulted in asystole after administration of physostigmine in TCA poisoned patient, its use has declined significantly.
However, physostigmine still possess limited but clinically useful role in the management of patients with antimuscarinic/anticholinergic induced delirium.
Recently, a prospective observational study was performed in the use of physostigmine when recommended by a regional poison center.
In 1 year study period, physostigmine was recommended by a regional poison center in 125 of 154 patients with suspected antimuscarinic/anticholinergic toxicity.
common exposures were
57 of 125 patients received physostigmine per treating team.
Of the remaining patients,
Adverse events (physostigmine group vs. non-physo group) - no statistically significant difference.
Physostigmine can safely control antimuscarinic/anticholinergic-induced delirium.
Boley SP et al. Physostimgine is superior to non-antidote therapy in the management of antimuscarinic delirium: a prospective study from a regional poison center. Clin Toxicol 2018 Jun 29:1-6. doi: 10.1080/15563650.2018.1485154. [Epub ahead of print]
Category: Critical Care
Legionella is an important cause of community-acquired pneumonia. It ranks among the three most common causes of severe CAP leading to ICU admission and carries a high mortality rate – up to 33%. Resulting from inhalation of aerosols containing Legionella species and subsequent lung infection, it is often associated with contaminated air conditioning systems, and other hot and cold water systems.
Recommended antibiotic regimens include a fluoroquinolone, either in monotherapy or combined with a macrolide (typically Levaquin +/- or Azithromycin).
A retrospective, observational study published in the Journal of Antimicrobial Chemotherapy in 2017 looked at 211 patients admitted to the ICU with confirmed severe legionella pneumonia treated with a fluoroquinolone vs a macrolide and monotherapy vs combination therapy. Combination therapy included fluoroquinolone + macrolide, fluoroquinolone + rifampicin, or macrolide + rifampicin.
Of these 211 cases, 146 (69%) developed ARDS and 54 (26%) died in the ICU. Mortality was lower in the fluoroquinolone-based group (21%) than in the non-fluoroquinolone based group (39%), and in the combination therapy group (20%) than in the monotherapy group (34%). In a multivariable analysis, fluoroquinolone-based therapy, but not combination therapy was associated with a reduced risk of mortality (HR 0.41).
Take Home Points:
-Remember, our usual blanket coverage with vanc + zosyn in the ED does not cover atypicals!
-Consider Levaquin instead of Azithro if there is clinical concern for Legionella PNA
-hyponatremia, abnormal LFTs may be clues in the appropriate context
Cecchini J, Tuffet S, Sonneville R, et al. Antimicrobial strategy for severe community-acquired legionnaires’ disease: a multicentre retrospective observational study. J Antimicrob Chemother. 2017;72(5):1502-1509. doi:10.1093/jac/dkx007.
Category: Pharmacology & Therapeutics
Keywords: Diabetes, DKA (PubMed Search)
Woodward RS, Flore MC, Machnicki G, Brennan DC. The long-term outcomes and costs of diabetes mellitus among renal transplant recipients: tacrolimus versus cyclosporine. Value Health. 2011;14(4):443-9.
Keywords: guidelines, protocols, safety, delirium (PubMed Search)
Based in part upon Geriatric Emergency Department Guidelines, the American College of Emergency Physicians has initiated a Geriatric Emergency Department Accreditation Program. Emergency departments (EDs) can be accredited at one of three levels- Gold (Level 1), Silver (Level 2) and Bronze (Level 3). There are various aspects upon which and EDs’ level is determined, including nurse and physician staffing and education, appropriate policies and protocols, quality improvement activities, outcome measures, equipment and the physical environment.
Keywords: capacity, dementia, altered mental status, medicolegal, ethics (PubMed Search)
Medical decision-making capacity refers to the patient’s ability to make informed decisions regarding their care, and emergency physicians are frequently required to assess whether a patient possess this capacity. Patients with acute or chronic neurological diseases (such as dementia) may lack this capacity, and this should be identified, especially in life-threatening situations. The patient must have the ability to:
communicate a consistent choice
understand (and express) the risks, benefits, alternatives and consequences
appreciate how the information applies to the particular situation
reason through the choices to make a decision
There are numerous tools that may help with this assessment, but none has been validated in the ED. Be careful of determining that the patient lacks capacity just because of the diagnosis they carry.
Capacity is a fluid concept; a patient may have the capacity to make simple decisions but not more complex ones. Capacity may also change over time
Psychiatry consultation to determine capacity is not obligatory but may be utilized for a second opinion.
Rodgers JJ, Kass JS. Assessment of Medical Decision-making Capacity in Patients With Dementia. Continuum 2018;24(3):920–925.
Category: Critical Care
Volume Responsiveness, Carotid Ultrasound, and the PLR
Gassner M, Killu K, Bauman Z, Coba V, Rosso K, Blyden D. Feasibility of common carotid artery point of care ultrasound in cardiac output measurements compared to invasive methods. Journal of Ultrasound. 2015;18(2):127-133.
ED visits for acute gout increased almost 27% between 2006 & 2014, a 26.8% increase
Presentation: Acute severe pain, swelling, redness, warmth.
Pain peaks between 12 to 24 hours and onset more likely at night
Quiet, calm period between flares vs other arthritic disorders
Signs of inflammation can extend beyond the joint
Normal to low serum urate values have been noted in 12 to 43% of patients with gout flares
Accurate time for assessment of serum urate is greater than 2 weeks after flare subsides
Most hyperuricemic individuals never experience a clinical event resulting from urate crystal deposition.
Gout flares may occasionally coexist with another type of joint disease (septic joint, psedugout),
A clinical decision rule has shown to be more accurate than clinical diagnosis (17 versus 36%)
*Male sex (2 points)
*Previous patient-reported arthritis flare (2 points)
*Onset within one day (0.5 points)
*Joint redness (1 point)
*First metatarsal phalangeal joint involvement (2.5 points)
*Hypertension or at least one cardiovascular disease (1.5 points)
*Serum urate level greater than 5.88 mg/dL (3.5 points)
Scoring for low (≤4 points), intermediate (>4 to <8 points), and high (≥8 points) probability of gout identified groups with a prevalence of gout of 2.2, 31.2, and 82.5 percent, respectively.
Consider supplementing your clinical decision with this in the future
Miathal A, Singh G. Emergency department visits for gout: a dramatic increase in the past decade. Oral presentation at the EULAR 2018 European Congress of Rheumatology in The Netherlands, June 13–16.
Kienhorst LB, et al. The validation of a diagnostic rule for gout without joint fluid analysis: a prospective study.Rheumatology (Oxford). 2015;54(4):609.
Becker, MA. Clinical manifestations and diagnosis of gout. Up to date. 2018
Keywords: DKA, cerebral edema, PECARN (PubMed Search)
Children with diabetic ketoacidosis (DKA) may have brain injuries ranging from mild to severe. The debate over the contribution from intravenous fluids towards poor neurologic outcomes has been ongoing for decades.
PECARN's large multicenter randomized, controlled trial examined the effects of the rate of administration and the sodium chloride content of intravenous fluids on neurologic outcomes in children with diabetic ketoacidosis may finally put the controversy to rest. There was no difference on significant neurologic outcomes based on the rate (fast vs slow) or concentration (0.9% vs 0.45%) of IV fluid administration.
Clinically apparent brain injury occurred in 12 of 1389 episodes (0.9%) of children in DKA.
Any change in the mental or neurological status of the patient should be concerning for life threatening edema and should be treated with mannitol 1g/kg IV bolus or hypertonic saline (3%) 5-10 mL/kg IV over 30 minutes.
Long, B; Koyfman, A. Emergency medicine myths: cerebral edema in pediatric diabetic ketoacidosis and intravenous fluids. J. Emerg. Med; 2017:53(2),212-221.
Category: Critical Care
Keywords: cardiac arrest, CPR, obesity (PubMed Search)
Although not specifically a part of current recommendations due to lack of data, the AHA has previously recommended shifting upward on the sternum during CPR in the pulseless pregnant patient in order to account for upward displacement of the heart by a gravid uterus. Should the same be done for our obese patients?
Lee et al. performed a retrospective study that reviewed chest CTs to determine the location on the sternum that corresponded to the optimal point of maximal left ventricular diameter (OPLV), in both obese and non-obese patients.
They found that the OPLV was higher (more cranial) on the sternum for obese patients than for patients with normal weight, although 96% of obese patients' OPLV fell within 2cm of where the guidelines recommend standard hand placement should be, compared to a notable 52% in non-obese patients.
*as measured from the distal end of the sternum
Bottom Line: Radiographically, the location on the sternum that corresponds to optimal compression of the LV is more cranial in obese patients than in non-obese patients. It remains to be seen whether the recommendations for hand placement in CPR should be adjusted, but we may want to consider staying within 4cm of the bottom of the sternum in patients of normal weight.
Lee J, Oh J, Lim TH, et al. Comparison of optimal point on the sternum for chest compression between obese and normal weight individuals with respect to body mass index, using computer tomography: A retrospective study. Resuscitation. 2018; 128:1-5.
Less than 1/2 of patients presenting to EDs and being diagnosed with concussion receive mild traumatic brain injury educational materials, and less than 1/2 of patients have seen a clinician for follow up by 3 months after injury.
In order to improve long term outcomes in patients with concusions please remember to provide the patient with approriate discharge instrucitons and strict instructions to follow up on their injury.
Full details of the article in JAMA can be found at https://jamanetwork.com/journals/jamanetworkopen/fullarticle/2681571
Keywords: Fever, infants, blood culture (PubMed Search)
The rate of occult bacteremia in infants 3 months to 24 months with a temperature higher than 40.5C was slightly higher when compared to those with a temperature higher than 39C.
363 infants (3 months to 24 months) with a fever > 40.5C who were well appearing were evaluated in this study. 4 were diagnosed with occult bacteremia (1.1%). 3 of these were caused by S. pneumoniae and 2 were fully immunized.
A larger sample size is needed to see if reconditions to include empiric blood cultures on this subgroup of patients is warrented.
After introduction of the pneumococcal conjugate vaccine, occult bacteremia dramatically decreased. Previous cost effective analysis showed that if the rate of occult bacteremia was less than 0.5%, then empiric testing should be eliminated, but if it is over 1.5%, then obtaining blood work is cost effective. In vaccinated patients, the occult bacteremia rates is less than 0.5%. These studies that showed this included patients with temperatures > 39C. This study looked at higher temperatures to see if there was a higher rate of occult bacteremia in this subgroup. In this ED, in all children with a temperature > 40.5C it was recommended that patients get a blood culture, WBC, ANC, CRP, UA, procalcitonin and PCR for pneumococcus and meningococcus regardless of immunization status. Further testing was at the discretion of the physician.
Gangoiti et al. Prevalence of Occult Bacteremia in Infants with Very High Fever without a source. Pediatr Infect Dis J. 2018 Feb. epub ahead of print.
Keywords: acute agitation, midazolam, antipsychotics, (PubMed Search)
Acutely agitated patients in the emegency room receive single or combination of benzodiazepine (lorazepam vs. midazolam) and antipsychotic (e.g. haloperidol) agents. Recently, use of ketamine has also been advocated to sedate agitated patients.
A recently published article compared IM administration several medications to treat acutely agitated patients in the ED. According to established protocol, each medication was administered in predetermined 3 week blocks:
N=737 with median age of 40 years, 72% men.
Midazolam resulted in greater proportion of patients with "adequate" sedation (altered mentatl status scale <1) compared to antipsychotics at 15 min post administration. Among antipsychotics, olanzapine resulted in greater proportion of patient with sedation.
Adverse effect were limited
Midazolam 5 mg IM achieve more effective sedation at 15 min in agitated ED patients than antipsychotics.
Klein LR et al. Intramuscular midazolam, olanzapine, ziprasidone or haloperidol for treating acute agitaion in the emergency department. Ann of Emerg Med 2018 June 6. pii: S0196-0644(18)30373-1. doi: 10.1016/j.annemergmed.2018.04.027. [Epub ahead of print]
Keywords: Syncope, neurological, neuroimaging, CT, MRI (PubMed Search)
Bottom Line: Consider obtaining neuroimaging in patients presenting with syncope only if clinical features suggest probable neurological syncope.