UMEM Educational Pearls

Category: Pharmacology & Therapeutics

Title: Esmolol for Refractory Ventricular Fibrillation (VF) or Pulseless Ventricular Tachycardia (VT)

Keywords: esmolol, cardiac arrest, ventricular tachycardia, ventricular fibrillation (PubMed Search)

Posted: 9/5/2020 by Ashley Martinelli (Updated: 10/28/2020)
Click here to contact Ashley Martinelli

Patients with cardiac arrest due to VF/VT have a higher likelihood of survival compared to those with unshockable rhythms.  Unfortunately some will still not survive even with following the AHA/ACLS algorithms leading to “refractory VF/VT.”  The survival rate of refractory VF/VT is 3-15%, with poor neurologic outcomes. 
 
Esmolol has been proposed as a treatment for the electrical storm of VF/VT to counteract the deleterious effect of beta receptor stimulation by epinephrine.
 
A recent meta-analysis of 3 trials of beta-blockade vs control patients for refractory VF/VT found:
 
Beta-blockade
N=22
Control
N= 44
OR/CI
Temporary ROSC, n (%)
19 (86.4)
14 (31.8)
OR 14.46, 95% CI 3.63-57.57
Sustained ROSC, n (%)
13 (59.1)
10 (22.7)
OR 5.76, 95% CI 1.79-18.52
Survival with neurological function, n (%)
6 (27.3)
4 (9.1)
OR 4.42; 95% CI 1.05-18.56
 
Takeaway: Esmolol needs to be studied further in prospective trials, but may be reasonable to attempt in refractory VF/VT.
 
Esmolol products:
§  Esmolol vial: 10 mg/mL (10mL)
o   Vial strength listed in mg, not mcg
o   Can cause complications with calculations, especially in high risk code scenario
§  Conversion of mg à mcg weight à based calculation 500mcg/kg
§  Do not ask anyone to do this calculation during a code!
§  Esmolol pre-made infusion: 2500 mg/250mL
o   Pump is set up to deliver weight based doses in mcg/kg
o   No mental math required!
 
How to do it at UMMC to limit mistakes in calculation:
1.       Obtain an esmolol pre-made infusion bag
2.       Program the pump for 50 mcg/kg/min continuous infusion (this is a required step in pump programming)
3.       Program the pump to give a 500 mcg/kg bolus x 1
4.       Permit the background infusion to run
5.       Can give an additional bolus of 500 mcg/kg x 1 and increase rate to 100 mcg/kg/min depending on clinical response

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Category: Pediatrics

Title: Temporizing Measures for Button Battery Ingestions

Keywords: button battery, pediatrics, esophageal injuries (PubMed Search)

Posted: 9/4/2020 by Prianka Kandhal, MD
Click here to contact Prianka Kandhal, MD

Ingestion of a button battery is a can't-miss diagnosis with a very high risk for causing severe esophageal injury. There are about 3000 button battery ingestions per year, and this is increasing because electronics are becoming more and more prevalent.

Severe damage to the esophagus occurs within 2 hours. On your lateral view, the end with narrowing is the negative end, which triggers a hydrolysis reaction that results in an alkaline caustic injury and, ultimately, liquefactive necrosis.

Children can present with nonspecific symptoms and if the ingestion was not witnessed, they are at high risk for delays in diagnosis. Additionally, in the community setting, there can be further delays in definitive treatment (endoscopic removal) due to difficulty in calling teams in or transporting to other facilities.

Anfang et al. looked into ways to mitigate damage to esophageal tissue. They did an in vitro study on porcine esophageal tissue, measuring the pH with different substances applied. They tried apple juice, orange juice, gatorade, powerade, pure honey, pure maple syrup, and carafate. They then repeated the study in vivo on piglets with button batteries left in the esophagus and ultimately did gross and histological examination of the esophageal tissue.

Honey and carafate demonstrated protective effects both in vitro and in vivo. They neutralized pH changes, decreased full-thickness esophageal injury, and decreased outward extension of injury into deep muscle.

Take Home Point: If a child is found to have a button battery in the esophagus, while definitive management is still emergent endoscopic removal, early and frequent ingestion of honey (outside of the hospital) and Carafate (in the hospital) may help reduce the damage done to the tissue in the interim. The authors recommend 10ml every 10 minutes.

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Category: Critical Care

Title: Early vs. Standard initiation of renal replacement therapy

Keywords: Renal Replacement Therapy (PubMed Search)

Posted: 9/1/2020 by Kim Boswell, MD (Updated: 10/28/2020)
Click here to contact Kim Boswell, MD

STARRT-AKITrial

The Standard versus Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury

The development of acute kidney injury (AKI) in the critical care setting portends a greater morbidity and mortality for patients. Additionally, it places the patient at high risk of complications and requires a greater use of resources. Several studies in the past have examined if the timing of initiation of renal replacement therapy (RRT) would result in a mortality benefit, but have failed to demonstrate consistent outcomes.

The STARRT-AKI trial was a multinational, randomized controlled trial designed to determine if early initiation of RRT in critically ill adult patients with AKI lowered the risk of 90-day mortality. The Kidney Disease Improving Global Outcomes (KDIGO) classification was used to define AKI and over 2900 patients were randomly assigned to two groups over a 4 year period. Exclusion criteria included: recent RRT, a renal transplant within the preceding year, advanced CKD, an overdose necessitating RRT, or a strong suspicion of obstruction or autoimmune/vascular cause of their AKI.

Groups:

  • The accelerated strategy group
    • Initiation of RRT within 12 hours of meeting eligibility criteria (AKI based on KDIGO definition)
  • The standard strategy group –
    • General goal of withholding RRT unless the patient met the following specific parameters:
    • K+ >6.0,  pH <7.20,  HCO3 <12mmol/L,  moderate ARDS with clinical picture concerning for volume overload, or persistent AKI >72hr after randomization

Outcomes/Results:

  • The study’s primary outcome measure was all cause mortality at 90 days
    •  There was no significant difference between the groups
    •  P=0.92 with RR 1.00
  • Secondary outcomes evaluated several things including ventilator and vasoactive free days, hospital length of stay, number of days without RRT at 90 days as well as adverse events directly related to RRT
    • Interestingly, at 90 days, the patients in the accelerated strategy group were more likely to have ongoing RRT needs at 10.4% compared to the standard strategy group at 6.0% (not statistically significant).
    •  Overall, no significant difference between the groups when assessed for death in the ICU, major adverse events, or with regard to hospital length of stay.

Take home points:

  • This was a well done, well randomized trial from many countries and ICU settings
  • No significant mortality benefit between groups at 90 days
  • Interestingly, the patients in the accelerated group were more likely to have suffered adverse events related to RRT and were more likely to be dependent on RRT at 90 days
    • It is unclear why this is, but suggestive that early initiation of RRT may compromise the intrinsic healing of the kidney
    • Emphasizes a greater risk for adverse events without clear benefit
  • Ultimately, the decision to initiate RRT should be based on the patient’s clinical picture, acid/base status, electrolyte abnormalities, and volume status and NOT on a general trend of their renal indices.

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Category: Neurology

Title: The Painful Twitch - Trigeminal Neuralgia

Keywords: trigeminal neuralgia, TN, tic douloureux, neuropathic facial pain (PubMed Search)

Posted: 8/26/2020 by WanTsu Wendy Chang, MD
Click here to contact WanTsu Wendy Chang, MD

  • Trigeminal neuralgia is diagnosed by:
    • Pain in 1 or more divisions of the trigeminal nerve
    • Paroxysms of pain that are sudden, intense, usually few seconds in duration
    • Pain triggered by innocuous stimuli in the trigeminal nerve territory (91-99% patients)
  • 24-49% of patients experience continuous or long-lasting pain
  • Exam may reveal forceful contraction of the facial muscles during a paroxysm (tic convulsif)
  • Causes include:
    • Intracranial vascular compression of the trigeminal nerve root (most common)
    • Multiple sclerosis, cerebellopontine angle tumor
    • Idiopathic (10% of cases)
  • Carbamazepine and oxcarbazepine are first-line treatments
    • They may be poorly tolerated due to side effects including dizziness, diplopia, ataxia, CNS depression, and hyponatremia
    • They also have limited efficacy on continuous pain
  • Acute exacerbations may warrant admission for hydration, acute pain control, and titration of antiepileptic drugs
    • Botulinum toxin A was recently added as a treatment option

Bottom Line: New onset trigeminal neuralgia needs workup for its etiology. Carbamazepine and oxcarbazepine can be effective for symptom management though continuous or long-lasting pain exacerbations are difficult to treat.

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Category: Critical Care

Title: Ketamine in the Critically Ill

Posted: 8/25/2020 by Mike Winters, MD (Updated: 10/28/2020)
Click here to contact Mike Winters, MD

Ketamine In the Critically Ill Patient

  • Ketamine has become a popular agent in the ED for both RSI and procedural sedation.
  • Given the sedative, analgesic, dissociative, antidepressant, and anti-inflammatory properties, ketamine has also been used in a number of other critical illness conditions including:
    • Acute pain management
    • Status asthmaticus
    • Alcohol withdrawal syndrome
    • Status epilepticus
    • Acute agitated delirium
  • The authors of a recent review in Critical Care Medicine found that the evidence supporting the use of ketamine in the critically ill is most robust for adjunctive analgesia in the intubated patient.  Surprisingly, the data is very limited to support the use of ketamine in these other conditions.
  • Pearl: ketamine does have a myocardial depressant effect, which can be unmasked in states of catecholamine depletion and result in hypotension and bradycadia.

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Category: Orthopedics

Title: Diagnostic performance of Ultrasound for detection of pediatric elbow fractures

Keywords: Elbow, fracture, ultrasound (PubMed Search)

Posted: 8/12/2020 by Brian Corwell, MD (Emailed: 8/22/2020) (Updated: 10/28/2020)
Click here to contact Brian Corwell, MD

Diagnostic performance of Ultrasonography for detection of pediatric elbow fracture

Elbow fractures account for approximately 15% of pediatric fractures

Fat pads are traditionally taught as a marker of fracture

In a cadaveric study:

Elbow effusions of 1-3 mL could be identified with ultrasound

Elbow effusions of 5-10 mL could be identified with plain film

Pediatric plain films are sometimes challenging to obtain and interpret compared to adults

              -More likely to be uncooperative in obtaining required views

              -Non-ossified epiphyses

Ultrasound may be used to detect

              -Cortical disruption and irregularity

              -Growth plate widening

              -Hematoma interposed between fracture fragments

              -Elevated posterior fat pad

Absence of elbow fracture was indicated by

              -Lack of cortical disruption

              -Absence of posterior fat pad sign

Meta-analysis of 10 articles totaling 519 patients using ultrasonography to detect elbow fractures

              Sensitivity 96%

              Specificity 89%

              False negative rate 3.7%             

For comparison, plain radiographs

Interpreted by peds EM physicians (87.5% sensitive and 100% specific)

Interpreted by radiology (96% sensitive, 100% specific)

 

Consider using ultrasound as a noninvasive, radiation-free modality for accurate diagnosis of pediatric elbow fractures.

 

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Category: Pediatrics

Title: Imperforate hymen

Keywords: Female GU, abdominal pain, missed period (PubMed Search)

Posted: 8/21/2020 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD

Definition: Congenital anomaly where the hymen is completely obstructing the vaginal opening

Demographic: Incidence 0.05-0.1% of females

History:  Most are asymptomatic and diagnosed on physical exam or incidentally when there is lack of menarche. Symptoms in adolescents can include: Abdominal pain (50%), urinary retention (20%), abnormal menstruation (14%), dysuria (10%), frequency, renal failure, UTI and back pain.

Physical exam: bulging, blueish hymenal membrane

Complications: Late detection can lead to infections, fertility problems, endometriosis, hydronephrosis, and rarely renal failure

ED treatment: If abdominal pain is significant or there is urinary obstruction, a urinary foley can be placed.  GYN should be consulted.

Definitive treatment: Hymenectomy, hymenotomy, carbon dioxide laser treatments or foley insertion through the hymen (done by a specialist).

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Category: Toxicology

Title: Baclofen clearance: hemodialysis or kidneys?

Keywords: baclofen overdose, hemodialysis, renal elimination (PubMed Search)

Posted: 8/20/2020 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

 

Baclofen is a presynaptic GABA-B receptor agonist in the spinal cord that is primarily used for muscle spasms/spasticity. In large overdose, baclofen can produce CNS depression, respiratory depression, bradycardia/hypotension, hypothermia, seizure and coma.

Baclofen is primarily eliminated by the kidney. In patients with end-stage kidney disease/acute kidney failure, hemodialysis (HD) has been used to enhance baclofen clearance. However, it is unclear if there is a benefit of using HD in patients with normal kidney function. 

In a recently published case report, HD was implemented in an attempt to shorten the anticipated prolonged ICU course. 

Case: 14 year old (51 kg) woman ingested 60 tablets of baclofen (20 mg tablets)

Her symptoms were:

  • Coma/CNS depression
  • Tonic-clonic seizure
  • Transient hypotension (95/47 mmHg – resolved with IV fluids)
  • Flaccid extremities
  • Initially intubated for airway protection --> no spontaneous breathing on mech. ventilation.

Baclofen level: 882 ng/mL (therapeutic range: 80 – 400 ng/mL)

Baclofen clearance from hemodialysis vs. urine

  • 24 hour urine output: 2810 mL --> total baclofen urinary elimination: 42 mg
  • 3 hours of HD #1: 3.05 mg removed. Total of 3 HD session performed.

Patient’s mental status improved on hospital day 6 and was extubated. She was discharged to psychiatry on hospital day 14.

 

 Conclusion:

  • Although this is a single case report, it appears that hemodialysis does not remove baclofen effectively.

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Category: Critical Care

Title: METCOVID

Keywords: COVID-19, ARDS, Pneumonia, Steroids (PubMed Search)

Posted: 8/17/2020 by Mark Sutherland, MD
Click here to contact Mark Sutherland, MD

Another week, another COVID-19 study...

On August 12th, the Metcovid study was e-published ahead of print in Clinical Infectious Diseases.  This was another study looking at steroids in COVID-19 pneumonia, this time performed in Brazil.  Metcovid was a parallel, double-blind, randomized, placebo-controlled phase IIb clinical trial which enrolled 416 patients at a single academic center for the evaluation of methylprednisolone (MP; 0.5 mg/kg BID x 5 days) vs placebo.  As with all COVID studies, Metcovid has some significant limitations, and some equivocal findings.  However, Metcovid was largely in line with RECOVERY and other trials looking at steroids in COVID-19, which lends it some face validity.  Metcovid found no significant difference in the primary outcome (mortality at day 28), but did find a difference in mortality in patients over 60 years old (a post-hoc analysis).  Metcovid was probably underpowered (sample size was based on a 50% reduction in mortality), and did have a very small trend towards reduced mortality in the MP group (37.1% vs 38.2%, p=0.629).

Bottom Line: 

  • Steroids (methylprednisolone 0.5 mg/kg BID x 5 days in this case) may have some mild benefit in severe cases of COVID-19 pneumonia, especially in patients who are elderly or have more aggressive inflammatory responses (as measured by CRP here).  
  • Steroids in COVID-19 may be associated with some theoretical downsides like reduced viral clearance, but are relatively safe.  Main side effect is the well known hyperglycemia induced by corticosteroids.
  • When using steroids in COVID pneumonia, both to stick with the evidence and for theoretical pharmacologic reasons, it may make sense to use dexamethasone or methylprednisolone, as these medications have a higher glucocorticoid:mineralocorticoid activity ratio.  It is hypothesized that using high mineralocorticoid steroids (like cortisone or hydrocortisone) may lead to increased water retention, which could be deterimental in ARDS.  This is purely theoretical.
  • There was a signal towards harm in younger and less sick patients in this study, and it probably remains prudent to reserve steroids for older, sicker COVID-19 pneumonia patients, similar to the RECOVERY trial.

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Category: Toxicology

Title: Physical exam findings in chronic nitrous oxide abuse

Keywords: nitrous oxide abuse, neurologic findings, physical exam (PubMed Search)

Posted: 8/13/2020 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

 

What physical exam findings are associated with nitrous oxide abuse?

 

 

 

 

Nitrous oxide (NO) inhalation abuse, also called “whip-its” or “whippets”, inactivates vitamin B12 and create a vitamin B12 deficiency state. Chronic abuse of nitrous oxide can result in neurologic deficits/findings affecting the posterior/dorsal column of the spinal cord. 

Physical exam findings: 

  1. Truncal ataxia
  2. Decreased vibratory sensation and proprioception in lower extremities
  3. Impaired coordination and rapid alternative movements
  4. Lhermitte’s sign: paresthesia of the upper and lower extremities associated with flexion of the head/neck.
  5. Rossolimo’s sign: exaggerated flexion of the toes when the tips of the toes are percussed

Category: Neurology

Title: Is That a CSF Leak?

Keywords: cerebrospinal fluid, rhinorrhea, otorrhea, halo, double ring, beta-2 transferrin (PubMed Search)

Posted: 8/12/2020 by WanTsu Wendy Chang, MD (Updated: 10/28/2020)
Click here to contact WanTsu Wendy Chang, MD

  • Spontaneous cerebrospinal fluid (CSF) rhinorrhea is rare and usually related to a combination of thinning of the bone and dura and fluctuating intracranial pressure.
  • CSF rhinorrhea can be associated with idiopathic intracranial hypertension, skull base tumors, neurosurgical and otolaryngology procedures, and trauma.
  • Trauma with fracture of the anterior skull base is the most common cause of CSF rhinorrhea.
  • CT and MRI can identify bony defects, whereas cisternography can diagnose occult leaks.
  • Fluid containing CSF is classically described to make a “halo” or “double-ring” pattern on gauze or linen.

  • However, this sign is not specific to CSF, as mixtures of blood with saline, tears, or rhinorrhea can also produce halos.
  • Beta-2 transferrin is a protein found almost exclusively in CSF* thus can be used to diagnose CSF rhinorrhea.

Bottom Line: Beta-2 transferrin is more accurate than the halo sign to identify CSF containing fluid.

Beta-2 transferrin is found in low concentrations in the perilymph in the cochlea, and aqueous and vitreous humor of the eye

 

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Category: Orthopedics

Title: Pronator Teres Syndrome

Keywords: Peripheral neuropathy, median nerve (PubMed Search)

Posted: 8/8/2020 by Brian Corwell, MD (Updated: 10/28/2020)
Click here to contact Brian Corwell, MD

Pronator Teres Syndrome

 

A compressive neuropathy of the median nerve in the region of the elbow

The median nerve passes through the cubital fossa and passes between the superficial and deep heads of the pronator teres muscle.

Rare compared to other compressive neuropathies such as carpal tunnel syndrome.

More common in women and in fifth decade of life

May be seen with weight lifters, arm wrestlers, rowers, tennis, archery, professional cyclists, dentists, fiddlers, pianists, harpists

Also associated with well-developed forearm muscles  

History:

Forearm pain – unlike carpal tunnel

Paresthesias in median distribution

No night symptoms – unlike carpal tunnel

Physical exam:

Sensory loss in medial nerve distribution.

Involves the thenar eminence!

Unlike carpal tunnel syndrome which doesn’t involve sensory loss in thenar eminence.

Pain may be made worse with resisted forearm pronation

Compression/Tinel’s sign over pronator mass reproduces symptoms

Treatment:

Splinting which limits pronation and NSAIDs

Steroid injection

Surgical nerve decompression is non operative treatment fails after greater than 6 months (rare)

 

 


Category: Critical Care

Title: HALT-IT Trial: TXA in GI bleeds

Keywords: gastrointestinal bleeding, TXA (PubMed Search)

Posted: 7/30/2020 by Lindsay Ritter, MD (Emailed: 8/4/2020) (Updated: 8/4/2020)
Click here to contact Lindsay Ritter, MD

Takeaways

Prior to this study, a Cochrane review and meta-analysis of TXA for upper GI bleeds with 7 trials (1654 patients), showed a large reduction in mortality with TXA (RR 0.61, 95% CI 0.42-0.98, p=0.01)

Design:

-Randomized, international, multicentre, placebo-controlled trial at 164 hospitals in 15 countries Juy 2013-2019

->16/18 years old with upper or lower GI bleeding

-1 g TXA IV over 10 minutes followed by maintenance dose 3 g TXA over 24 hours 

 

Results:

-Main outcome death due to bleeding within 5 days 

-4% (222/5994) died in TXA group vs 4% (226/5981) placebo risk ratio RR 0.99, 95% CI 0.82-1.18 

-Arterial thromboembolic events MI/CVA similar in both groups (0.7% vs 0.8%)

-Venous thromboembolic events PE/DVT higher in TXA group (0.8% vs 0.4%)

 

Pitfalls:

-Initially calculated all cause mortality until realization that over half deaths were due to non-bleeding causes, changed to death related to bleeding, allowing study appropriate power to detect difference 

-Majority of patients had UGIB/variceal bleeding due to liver disease, over 75% deaths in those with liver disease 

-Only 16% patients randomized in <3 hours, most >8 hours (CRASH-2 trial found benefit TXA in trauma patients only <3 hrs to administration) 

 

Takeaway:

-TXA should not be used in the management of GI bleeds

-Increased venous thromboembolic events associated with TXA administration for GI bleeds

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Category: Pharmacology & Therapeutics

Title: Pain Management in Cirrhosis

Keywords: Cirrhosis, Pain, Acetaminophen, NSAID, Opioid (PubMed Search)

Posted: 8/1/2020 by Wesley Oliver (Updated: 10/28/2020)
Click here to contact Wesley Oliver

The liver performs an essential role in the metabolism and clearance of many drugs. Liver damage due to cirrhosis can decrease first-pass metabolism of oral medications and increase free-drug concentrations of protein-bound medications due to decreased albumin production. In the absence of cirrhosis, patients with chronic hepatitis or hepatic cancer may only have a small decrease in drug clearance. Hepatic dose adjustments are not as prevalent or readily available as renal dose adjustments, which can create difficulty in finding the balance between pain relief and adverse effects.

The most common medications used for pain control in the emergency department are acetaminophen, NSAIDs, and opioids.

Acetaminophen

It is sometimes misconceived that acetaminophen should never be used in patients with cirrhosis due to the common knowledge that acetaminophen overdoses can cause hepatotoxicity. Alcoholics may have an increased risk of hepatotoxicity due to induction of CYP2E1 and decreased glutathione stores. However, acetaminophen is safe in patients with cirrhosis when used at appropriate doses. Limit the total daily dose of acetaminophen to 2 g daily in patients with cirrhosis and avoid acetaminophen in patients that are actively drinking.  Also, educate patients that over-the-counter (OTC) and prescription medications may contain acetaminophen.

NSAIDs

In patients with cirrhosis, NSAIDs have increased bioavailability due to decreased CYP metabolism and decreased protein binding. In addition, prostaglandin inhibition can precipitate renal failure and sodium retention, worsening ascites and increasing the risk of hepatorenal syndrome, and increase the risk of gastrointestinal bleeding. Thrombocytopenia from NSAID use can further increase the risk of bleeding. Thus, avoid NSAID use in patients with cirrhosis. Topical NSAIDs can be considered.

Opioids

Opioid metabolism is altered in patients with cirrhosis and can contribute to complications with cirrhosis, such as precipitating encephalopathy. Generally, the bioavailability is increased and half-life is extended; thus, lower doses of immediate-release (IR) formulations at extended dosing intervals should be utilized. Common opioids for acute pain control in the emergency department are fentanyl, hydrocodone/oxycodone, hydromorphone, and morphine.

  • Fentanyl: Largely unaffected by cirrhosis. High potency so utilize only in appropriate clinical situations.
  • Hydrocodone/Oxycodone: Metabolized by CYP to active metabolites (hydromorphone/oxymorphone). Due to decreased CYP metabolism, analgesia may be less potent and clearance decreased. Also, be aware that some formulations are combined with acetaminophen.
  • Hydromorphone: Metabolized by glucuronidation to inactive metabolite. Metabolism and clearance less affected by cirrhosis.
  • Morphine: Increased bioavailability and concentration due to decreased first-pass metabolism. Decreased clearance and longer half-life. Avoid use in renal impairment and hepatorenal syndrome due to risk of neurotoxic metabolite accumulation.
  • Tramadol, codeine, meperidine, methadone, and buprenorphine not recommended for acute pain control in the emergency department.

 

 

Take Home Points

Drug/Class

Preferred Agent

Considerations

Acetaminophen

Max daily dose 2 g/day

Avoid if actively drinking. Be cautious if patient also taking OTC or combination products.

NSAIDs

None; Avoid

Topical NSAIDs may be considered.

Opioids

Hydromorphone, Fentanyl

Start with IR products at lower doses and extended intervals.

 

Show References


Patient 

  • Single Center, double-blinded, randomized trial. 

  • Patients with cancer and septic shock 

Intervention 

  • 4% albumin + lactate ringer bolus in 10 minutes 

  • 180 patients 

Comparison 

  • Lactate ringer bolus in 10 minutes 

  • 180 patients 

Outcome 

  • Primary: Any mortality within 7 days of randomization. 

  • Secondary: Mortality within 28 days, renal replacement therapy (RRT) 

Results: 

  • 7-day mortality: 46 (25%) for LR + albumin vs. 40 (22%) for LR only 

  • 28-day mortality: 96 (53%) for LR + albumin vs. 83 (46%) for LR only 

  • RRT: 16 (9%) for LR + albumin vs. 12 (7) for LR only 

Conclusion: 

Adding albumin for early resuscitation to crystalloids did not improve mortality in cancer patients with septic shock. 

 

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Category: Pediatrics

Title: Risk factors for pediatric cervical spine injuries

Keywords: MVC, neck injury, neurological injury (PubMed Search)

Posted: 7/24/2020 by Jenny Guyther, MD (Updated: 10/28/2020)
Click here to contact Jenny Guyther, MD

There is no well validated clinical decision rule similar to NEXUS or the Canadian Cervical Spine rule in children for clearing the cervical spine.  Clinical clearance versus imaging first is a complicated decision.  Certain risk factors may predispose children to injury and should be taken into account when deciding about clinical clearance versus imaging (XR).

High Risk Criteria for Cervical Spine Injury in Pediatrics

Mechanism

 

High risk MVC

              Intrusion > 12 inches at the occupant site

              Intrusion > 18 inches at any site

              Partial or complete ejection

              Death in the same passenger compartment

              Vehicle telemetry consistent with high speed

Fall > 10 feet

Nonaccidental trauma

Diving injury

History

 

Down’s Syndrome

22.q11.2 deletion

Klippel-Fiel syndrome

Physical Exam

 

Altered mental status

Intoxication

Hypotension

Focal neurological exam

Neck pain

Torticollis

             

 

 

 

 

 

 

Show References


Category: Toxicology

Title: "Tianna Red" - Tianeptine, a new medication of abuse?

Keywords: tianeptine, clinical characteristics, poison center (PubMed Search)

Posted: 7/23/2020 by Hong Kim, MD, MPH
Click here to contact Hong Kim, MD, MPH

 

Tianeptine is an antidepressant with mu-opioid receptor agonism. It is available in several European countries for therapeutic use, but not available in the US.

There has been an increase in tianeptine exposure in the US since August 2019. Recently a retrospective observation study was done to characterize the clinical features associated with tianeptine exposure. 

Result

  • 48 cases of tianeptine exposure were identified from January 1, 2015 to March 15, 2020 from a single poison center
  • 37 cases (77%) occurred from May 2019 to March 2020.

Intoxication (n=11)

Withdrawal (n=27)

Symptoms 

·      Lethargy: 7 (63%)

·      Agitation: 3 (27%)

·      Tachycardia: 3 (27%)

·      GI distress: 2 (18%)

·      Myoclonic/hallucination: 2 (18)

Symptoms

·      Anxiety: 12 (44%)

·      GI distress: 3 (33%)

·      Hypertension: 8 (30%)

·      Agitation: 8 (30%)

·      Tachycardia: 7 (26%)

Treatment

·      Naloxone: 3 (27%)

·      Benzodiazepines: 2 (18%)

·      Antipsychotics: 2 (18%)

·      Antimuscarinic: 1 (9%)

 

Treatment

·      Benzodiazepine: 10 (37%)

·      Opioids: 6 (22%)

·      Alpha-2-agonist: 5 (19%)

·      Antipsychotics: 5 (19%)

·      Antimuscarinic: 5 (19%)

Disposition

·      ICU: 6 (55%)

·      Non-ICU: 2 (18%)

·      Discharged home: 2 (18%)

 

Disposition

·      ICU: 4 (15%)

·      Non-ICU: 7 (26%)

·      Psych: 1 (4%)

·      Discharged home: 10 (37%)

 

Conclusion

  • Tianeptine exposure is increasing in the US .
  • Intoxication frequently results in lethargy and/or agitation.

Show References


Design
-Two-center prospective observational study with 157 patients admitted to the ICU for pneumonia and being treated with HFNC
-ROX (Respiratory rate-OXygenation) index = ratio of SpO2/FIO2 to RR

Results:
-ROX index ≥4.88 at 12 hours after HFNC onset with a sensitivity of 70.1%, a specificity of 72.4%, PPV of 89.4%, NPV of 42%, LR+ of 2.54, and LR- of 0.41 in predicting treatment failure

Validation study: Roca, 2019
-results similar, but ROX index ≥4.88 at 12 hour with LR+ of only 1.82
-also found that a ROX index of <3.85 at 12 hours had a sensitivity of 23.5%, specificity of 98.4%, PPV of 88.9, NPV 69.9, LR+ of 14.47, and LR- 0.78

Pitfalls:
-decision to intubate was not made based on ROX index
-criteria for intubation was also part of the ROX index
-NIV was not part of their treatment algorithm
-created and validated prior to current COVID-19 pandemic

Takeaways:
- The ROX index can be a tool to help predict whether a patient with pneumonia on HFNC may need mechanical ventilation or higher level of care
- May be most helpful with patients with pneumonia on HFNC boarding in the ED
- At 12 hours of HFNC, ROX index of >4.88 suggests patient likely to succeed with HFNC vs. <3.85 which suggests likely need for mechanical ventilation

Show References


Category: Critical Care

Title: Dexamethasone: Improving Mortality in COVID-19?

Keywords: dexamethasone, steroids, respiratory failure, COVID-19, SARS-CoV-2, RECOVERY (PubMed Search)

Posted: 7/14/2020 by Kami Windsor, MD
Click here to contact Kami Windsor, MD

 

The RECOVERY (Randomized Evaluation of COVid-19 thERapY) investigators recently published a non-peer reviewed article on their findings utilizing dexamethasone to treat patients with COVID-19. 

Rx: Dexamethasone 6mg daily* x 10 days (PO or IV) *or steroid equivalent

  • 2104 in the dexamethasone group vs 4321 in the “usual care” group
  • Did not exclude children or pregnant/breastfeeding mothers
  • Follow-up at 28 days, hospital discharge, or death

Primary outcome:         All-cause mortality at 28-days

Secondary outcomes: 

  • Major arrhythmia
  • Time to discharge from hospital
  • Duration of mechanical ventilation
  • Need for renal replacement therapy
  • In patients not ventilated at enrollment, need for intubation/ECMO & death

Results:

  • Decrease in overall mortality at 28-days with 3% absolute risk reduction.
    • NNT of 25 in patients requiring O2, HFNC, or NIV
    • NNT of 8 in patients requiring invasive mechanical ventilation
  • More mortality benefit seen the higher the respiratory support required, with no benefit and apparent trend towards increased mortality in the group not requiring any respiratory support at all. 
  • When stratified by symptoms < or > 7 days, mortality benefit only seen in the >7 days group (which was more of the ventilated patients).
  • Less progression to intubation, shorter hospital duration, greater likelihood of hospital discharge.

Limitations:

  • Not yet peer-reviewed, haven't seen all the data, additional analyses could be helpful in determining if treatment effect is real
  • Unblinded study
  • 7% of control group received dexamethasone

 

Bottom Line: Strongly consider admininstering dexamethasone to your patients with known COVID-19 who require respiratory support, and look for the peer-reviewed publication from the RECOVERY Trial investigators.

 

Show References


Category: Orthopedics

Title: Treatment for carpal tunnel syndrome (CTS)

Keywords: carpal tunnel syndrome, neuropathy, (PubMed Search)

Posted: 7/11/2020 by Brian Corwell, MD (Updated: 10/28/2020)
Click here to contact Brian Corwell, MD

Treatment for carpal tunnel syndrome (CTS)

The management of CTS depends of the severity of the disease

If symptoms or on the mild to moderate range, a trial of conservative treatment is encouraged.

Possible therapeutic approaches can include splinting in wrist neutral position. Some even extend to keep the CMP joints extended. Extreme flexion and extension can increase pressure within the carpal tunnel. Usually for nighttime use only. May be used during day based on work and activity demands.

Has been shown to improve electrophysiologic findings after 12 weeks of use in moderate CTS.

Formal hand physical therapy (by an experienced therapist) may also be of some benefit including carpal bone mobilization, ultrasound and nerve glide exercises.   

There is small evidence for the benefit of prednisone (20mg/d) as it has been shown to be more effective than placebo with improvements lasting an average of 8 weeks.

There is no benefit to NSAIDs or diuretics.

There is poor evidence for therapeutic ultrasound and acupuncture.

While more invasive than the above modalities, steroid injections may decrease inflammation and pressure in the carpal tunnel.  Patients randomized to steroid injection may do better than those randomized to nighttime splinting.

Early referral in those with positive electrodiagnostic findings is encouraged as they do best with earlier surgical release and have better recovery.

If however the patient has severe, progressive or persistent symptoms or there is known evidence of nerve injury on diagnostic testing, referral for surgical decompression is warranted.