Keywords: discharge planning, elderly (PubMed Search)
Elderly patients (mean age of 84 years) living in the community who are seen and discharged from the Emergency Department due to illness or injury are at increased risk for further disability and functional decline for at least six months after their visit. This is associated with increased mortality, cost and need for long term care in previously self-functioning individuals. * When appropriate to discharge from the ED, we should consider discharge planning that includes coordination with care management services to be sure these individuals have adequate home support systems in place and access to close outpatient follow-up.
*It should be noted that the risk is even greater after inpatient hospitalization.
Nagurney, Justine M. et al., Emergency Department Visits Without Hospitalization Are Associated With Functional Decline inOlder Persons, Annals of Emergency Medicine, 2016; 69(4): 426 – 433. doi.org/10.1016/j.annemergmed.2016.09.018.
Category: Pharmacology & Therapeutics
Keywords: Serotonin Syndrome, SHIVERS (PubMed Search)
Identifying serotonin syndrome in the emergency department can be difficult without an accurate patient history. Furthermore, the physical symptoms may look similar to many other disorders such as neuroleptic malignant syndrome and anticholinergic toxicity. If you remember the acronym SHIVERS, you can easily recognize the signs and symptoms of serotonin syndrome.
Shivering: Neuromuscular symptom that is unique to serotonin syndrome
Hyperreflexia and Myoclonus: Seen in mild to moderate cases. Most prominent in the lower extremities. This can help differentiate from neuroleptic malignant syndrome which would present with lead-pipe rigidity.
Increased Temperature: Not always present, but usually observed in more severe cases
Vital Sign Abnormalities: Tachycardia, tachypnea, and labile blood pressure
Encephalopathy: Mental status changes such as agitation, delirium, and confusion
Restlessness: Common due to excess serotonin activity
Sweating: Autonomic response to excess serotonin. This symptom can help differentiate from anticholinergic toxicity in which the patients would present with increased temperature but dry to the touch
Once serotonin syndrome is identified, it is important to discontinue all serotonergic agents, provide supportive care with fluids, and sedate with benzodiazepines. Sedation with benzodiazepines helps to decrease myoclonic jerks which also helps with temperature control. If patients are hyperthermic, they will require intensive cooling. Cyproheptadine, a potent antihistamine and serotonin antagonist, should also be administered. The initial dose of cyproheptadine in serotonin syndrome is 12mg which can be followed by 2 mg every 2 hours as needed for symptom control.
2. Ables AZ, Nagubilli R. Prevention, Recognition, and Management of Serotonin Syndrome. AFP. 2010;81(9):1139-1142.
Keywords: lipid emulsion therapy (PubMed Search)
Intravenous lipid emulsion (ILE) is use as a therapy of last resort in refractory cardiovascular shock from toxicity of select agents (e.g. calcium channel blockers, beta blockers and select Na-channel blocking agents). There are number of case reports/series that showed positive cardiovascular/hemodynamic response after ILE, which are prone to publication bias. Results from limited number of human trials have shown mixed results.
A study reviewed fatal cases of poisoning that received ILE from the National Poison Data System to characterize the clinical response of ILE therapy.
N=459 cases from 2010 to 2015.
Most common substance involved
Number with ROSC (%)
Local anesthetics – parenteral*
*Use of ILE supported by Lipid work group
Possible adverse reactions (n)
Category: Critical Care
The Lung Transplant Patient in Your ED
Welte T, et al. Ten tips for the intensive care management of transplanted lung patients. Intensive Care Med. 2019; 45:371-3.
Hospitalization for Suicide Ideation or Attempt: 2008-2015. Pediatrics. Pelmons. 2018
Special Considerations in the Pediatric Psychiatric Population. Psychiatric Clinics. Santillanes 2017.
Sarah Edwards, DO. Medical & Program Director. Child and Adolescent Psychiatry. University of Maryland School of Medicine.
Keywords: Scromboid, Histamine (PubMed Search)
Scromboid (histamine fish poisoning) can be easily misdiagnosed since its' clinical presentation can mimic that of allergy. Seen most frequently in the summer and occurring with Scombroideafish (tuna, mackerel, bonito, skipjack) but also with large dark meat fish (sardines and anchovies) and even more commonly with nonscromboid fish such as mahi mahi and amber jack. In warm conditions when fish is improperly refrigerated, bacterial histidine decarboxylase converts muscle histidine into histamine which quickly accumulates. Histamine is heat stable and not destroyed with cooking.
Scromboid poisoning is due to histamine ingestion and is often misdiagnosed as allergic reaction. It is preventable with proper fish storage.
Severe scombroid fish poisoning: an underrecognized dermatologic emergency. Jantschitsch C, Kinaciyan T, et al. J Am Acad Dermatol 2011; 65:246–7.
Histamine fish poisoning: a common but frequently misdiagnosed condition. Attaran RR, Probst F. Emerg Med J 2002;19:474–5.
Category: Critical Care
Keywords: heart transplant, arrhythmias, critical care (PubMed Search)
When managing transplant patients it is important to keep in mind the anatomic and physiologic changes that occur with the complete extraction of one person's body part to replace another's.
For cardiac transplant patients with symptomatic bradycardia:
For cardiac transplant patients with tachyarrythmias:
Stecker EC, Strelich KR, Chugh SS, et al. Arrythmias after orthotopic heart transplantation. J Card Fail. 2005;11(6):464-72.
Thajudeen A, Stecker EC, Shehata M, et al. Arrhythmias after heart transplantation: Mechanisms and management. J Am Heart Assoc. 2012;1(2):e001461.
Category: Critical Care
Hyponatremia in the Brain Injured Patient
Mrozek S, et al. Pharmacotherapy of sodium disorders in neurocritical care. Curr Opin Crit Care. 2019; 25:132-7.
Keywords: Spine infection, back pain (PubMed Search)
Laboratory testing for Spinal Epidural Abscess
The CBC is poorly sensitive/specific
The WBC count may be nml or elevated
Left shift and bandemia may or may not be present
ESR and CRP
Sensitive but not specific
Elevated in >80% with vertebral osteomyelitis.
Reihsaus E, et al. Spinal epidural abscess: a meta-analysis of 915 patients. Neurosurg Rev 2000.
Keywords: headache, back pain, misdiagnosis, stroke, intraspinal, epidural, abscess (PubMed Search)
Bottom Line: The rate of serious neurologic conditions missed at an initial ED visit is low. However, the potential harm of misdiagnosis can be substantial.
Keywords: kratom, adverse effects, poison center data (PubMed Search)
Kratom (Mitragyna speciosa) has been used for centuries in Southeast Asia to manage pain and opium withdrawal. It is increasingly being used in the U.S. for similar purpose. The U.S. DEA lists Kratom as a “drug of concern”.
Effects of Kratom leaves
A study reviewed National Poison Data System (2011 to 2017) to evaluate the clinical effects/outcomes of Kratom exposure.
Finding: (N=1807; single-substance: 1174; multiple-substance: 633])
Sara Post, Henry A. Spiller, Thitphalak Chounthirath & Gary A. Smith (2019): Kratom exposures reported to United States poison control centers: 2011–2017, Clinical Toxicology, DOI: 10.1080/15563650.2019.1569236
Category: Critical Care
Keywords: Airway management, acute respiratory failure, hypoxia, intubation, preoxygenation (PubMed Search)
The PROTRACH study recently compared preoxygenation with standard bag valve mask (BVM) at 15 lpm to preoxygenation + apneic oxygenation with high flow nasal cannula 60 lpm/100% FiO2 in patients undergoing rapid sequence intubation.
Guitton C, Ehrmann S, Volteau C, et al. Nasal high-flow preoxygenation for endotracheal intubation in the critically ill patient: a randomized clinical trial. Intensive Care Med. 2019. doi: 10.1007/s00134-019-05529-w. [Epub ahead of print]
Keywords: back pain, back emergency (PubMed Search)
Cauda Equina Syndrome (CES)
A recent pearl discussed CES. This is a very challenging diagnosis to make, especially on initial presentation
The 5 “classic” characteristic features are
Not all symptoms will be present in a given patient and there is no sign/symptom combination that either reliably diagnoses or excludes CES.
To illustrate how difficult this diagnosis is to make, a study looked at the predictive abilities of Neurosurgical residents.
Positive MRI for CES was accurately predicted by senior neurosurgical residents in approximately 50% of patients suspected of CES based on history and physical findings. As clinical certainty only becomes apparent with the classic symptoms (which are generally late findings) waiting to initiate MRI will delay decompressive surgery and can lead to worsened functional outcomes. This leads to increased MRI demand with more negative MRIs. Not surprisingly, only ~20% of MRI scans for suspected CES are positive.
Bell DA et al. Cauda equina syndrome: what is the correlation between clinical assessment and MRI scanning? Br J Neurosurg 2007;21:201-3.
Category: Critical Care
A True Tracheostomy Emergency
Przbylo JA, Wittels K, Wilcox SR. Respiratory distress in a patient with a tracheostomy. J Emerg Med. 2019; 56:97-101.
Category: Pharmacology & Therapeutics
Keywords: bleeding, epistaxis, tranexamic acid (PubMed Search)
Mechanism of Action
Tranexamic Acid (TXA) is an antifibrinolytic agent that is a competitive inhibitor of plasminogen activation, and a non-competitive inhibitor of plasmin
Inhibits the breakdown of fibrin mesh allowing clot formation
When is it Indicated?
Epistaxis/Oral Bleeds/Fistula Bleeds
Keywords: spinal cord, physical exam, assessment (PubMed Search)
Back pain with lower extremity symptoms can be concerning for cauda equina. Some pointers regarding the H&P:
None of these symptoms independently predicts cauda equina syndrome with an accuracy greater than 65%.
Bottom Line: do not depend on any one finding to reliably exclude or confirm cauda equina.
Shapiro S. Medical realities of cauda equina syndrome secondary to lumbar disc herniation. Spine (Phila Pa 1976). 2000;25(3):348-351; discussion 352
Gardner A, Gardner E, Morley T. Cauda equina syndrome: a review of the current clinical and medico-legal position. Eur Spine J. 2011;20(5):690-697. (Review article)
Bell DA, Collie D, Statham PF. Cauda equina syndrome: what is the correlation between clinical assessment and MRI scanning? Br J Neurosurg. 2007;21(2):201-203
Category: Critical Care
Keywords: ARDS, respiratory failure, ventilator settings, critical care (PubMed Search)
Despite ongoing research and efforts to improve our care of patients with ARDS, it remains an entity with high morbidity and mortality. Early recognition of the disease process and appropriate management by emergency physicians can have profound effects on the patient's course, especially in centers where ICU boarding continues to be an issue.
Recognition of ARDS (Berlin criteria)
*An ABG should be obtained in the ED if physicians are unable to wean down FiO2 from high settings, if oxygenation by pulse ox is marginal, or if the patient is in a shock state.
Tenets of ARDS Management:
*IBW Males = 50 + 2.3 x [Height (in) - 60] / IBW Females = 45.5 + 2.3 x [Height (in) - 60]
Strategies for Refractory Hypoxemia in the ED: You can't prone the patient, but what else can you do?
1. Escalate PEEP in stepwise fashion
2. Recruitment maneuvers
3. Appropriate sedation and neuromuscular blockade
4. Inhaled pulmonary vasodilators (inhaled prostaglandins, nitric oxide) if known or suspected right heart failure or pulmonary hypertension
Bottom Line: Emergency physicians are the first line of defense against ARDS. Early recognition of the disease process and appropriate management is important to improve outcomes AND to help ICU physicians triage which patients need to be emergently proned or even who should potentially be referred for ECMO.
Fielding-Singh V, Matthay MA, Calfee CS. Beyond Low Tidal Volume Ventilation: Treatment Adjuncts for Severe Respiratory Failure in Acute Respiratory Distress Syndrome. Crit Care Me.. 2018;46(11):1820-31.
Keywords: low back pain, analgesia (PubMed Search)
In patients with lower back pain, there is good evidence that muscle relaxants reduce pain as compared to placebo and that different types are equally effective. However, the high incidence of significant side effects such as dizziness and sedation limits their use. Muscle relaxants may be beneficial in an every bedtime capacity thereby limiting side effects.
If cyclobenzaprine is used during daytime hours, a lower dose schedule may work as well as a higher dose with somewhat less somnolence (5 mg three times a day vs 10 mg three times a day. In general, muscle relaxants should only be used when patients cannot tolerate NSAIDs but can tolerate the side effect profile.
We commonly add muscle relaxants to NSAIDs hoping for a larger analgesic effect. However, combination therapy does not appear to be better than monotherapy.
Adding cyclobenzaprine to high-dose ibuprofen does not seem to provide additional pain relief in the first 48 hours in ED patients with acute myofascial strain. Among an ED population with acute non radicular low back pain, a randomized trial found that adding cyclobenzaprine/other muscle relaxants to Naproxen did not improve functional outcomes or pain at one week or 3 months compared to naproxen alone.
Take home: Consider the limited usefulness use of muscle relaxants in ED patients with back pain
Friedman et al., 2015. JAMA.
Keywords: CCHD, congenital cardiac lesions, congenital heart disease (PubMed Search)
The hyperoxia-hyperventilation test (aka 100% Oxygen Challenge test) is used to differentiate the cause of central cyanosis in the sick neonate. The majority of neonatal cyanosis is caused by either cardiac or respiratory pathology.
Classically the test is performed as follows:
1. An ABG is obtained with the neonate breathing room air
2. The patient is placed on 100% FiO2 for 10 minutes
3. A repeat ABG is performed looking for an increase in PaO2 to >150 mmHg
- If the hypoxia is secondary to a respiratory cause, the PaO2 should increase to >150 mmHg.
- If the hypoxia is secondary to a congenital cardiac lesion (i.e. secondary to a right-to-left cardiac shunt) the PaO2 is not expected to rise significantly.
In practice, many physicians instead use pulse oximetry and monitor the SpO2 pre and post administration of 10 minutes of 100% FiO2.
- If after 10min of 100% FiO2, if SpO2 is not ? 95% (some resources use 85%) then the central cyanosis is likely secondary to intracardiac shunt.
- When this occurs, presume the sick neonate is symptomatic from a congenital cardiac lesion and initiate prostaglandin E-1 (PGE1) at 0.05-0.01 mcg/kg/min. Use caution as PGE1 may cause apnea.
Keywords: CT, Overdose, Pills (PubMed Search)
The primary tenet of poisoning treatment is to separate the patient from the poison. Gastric decontamination has been the cornerstone of poisoning treatment throughout history and methods include induced emesis, nasogastric suctioning, EGD or gastrostomy retrieval, activated charcoal, and whole bowel irrigation. Current guidelines for gastic decontamination are limited to few clinical situations. The detection of residual life threatening poisons in the stomach would be of value in predicting who might benefit from gastric decontamination in overdose.
Plain radiographs have variable sensitvity in detecting radioopaque pills. Computed tomography (CT) has been successful and gained wide acceptance in the detection of drug in body packers. In a recent study, authors studied the usefulness of non-contrast abdominal computed tomography for detection of residual drugs in the stomach in patients presenting over 60 minutes from acute drug overdose:
Non-contrast CT may help to predict which patients would benefit from gastric decontamination in acute life-threatening drug poisonings.
Position paper update: gastric lavage for gastrointestinal decontamination. Benson B, Hoppu K, et al. Clin Toxicol. 2013;51:140–146.
American Academy of Clinical Toxicology & European Association of Poisons Centres and Clinical Toxicologists (2005) Position Paper: Single-Dose Activated Charcoal, Clinical Toxicology, 43:2, 61-87.
Are ingested lithium sulphate tablets visible on x-ray? A one-year prospective clinical survey. Höjer J, Svanhagen AC. 2012. Clinical Toxicology, 50:9, 864-865.
The usefulness of non-contrast abdominal computed tomography for detection of residual drugs in the stomach of patients with acute drug overdose, Yong Sung C, Seung-Whan C, et al. 2019. Clinical Toxicology.