UMEM Educational Pearls

The Romberg test is part of the standard neurologic examination. The patient is asked to stand with feet together, hand on hips/sides and the eyes are closed. Vestibular and proprioceptive input is being tested. 

This test is not very sensitive overall, but especially in concussed athletes.

Many concussed athletes are able to stand relatively stable despite their neurologic injury.

In order to better identify postural instability in concussion, we perform 3 separate balance tests (modified balance error scoring system, mBESS).

A) Romberg

B) Single leg stance

21. Standing on the non dominant foot, the hip is flexed to approximately 30° and the is knee flexed to approximately 45°.
21. NonDominant Leg: The nondominant leg is defined as the opposite leg of the preferred kicking leg

C) Tandem Stance

https://www.researchgate.net/profile/Boaz_Saffer/publication/309591285/figure/fig2/AS:669641529626644@1536666390860/Balance-Error-Scoring-System-BESS-performed-on-firm-surface-A-C_W640.jpg

Have patient stand quietly with hands on hips

Have patient close eyes and start 20 second trial

If error occurs tell patient to return to start as quickly as possible

Examples of errors: opening eyes, lifting hands, falling out of position

Antimuscarinic agents (e.g. diphenhydramine) are one of the commonly ingested substances in the US. Lorazepam is frequently used to treat delirium and agitation associated with antimuscarinic toxicity. Although physostigmine is also effective, its use is infrequent due to concerns of safety and provider’s limited experience with physostigmine.

A small blinded randomized clinical trial was conducted to compare physostigmine vs lorazepam for the treatment of antimuscarinic toxicity -delirium/agitation. 

Inclusion criteria

• Age: 10-17 years old
• At least one central and 2 peripheral antimuscarinic symptoms
• Delirium and moderate agitation

Intervention

1. Lorazepam 0.05 mg/kg IV bolus (max 2 mg). this dose could be repeated at 10 min if needed. then a 4 hr normal saline infusion 
2. Physostigmine 0.02 mg/kg IV bolus (max 2 mg; over 3-5 min). this dose could be repeated at 10 min if needed. then 0.02 mg/kg/hr (max 2 mg/h) physostigmine infusion for 4 hours.

Plus administration of lorazepam (0.05 mg/kg) IV bolus (max 2 mg) every 2 hours as needed for continued agitation or delirium (at the discretion of treatment team)

Delirium and agitation were assessed by Confusion Assessment Method for the Intensive Care Unit score (CAM-ICU) and Richmond Agitation Sedation Score

Result

Study duration: March 20, 2017 to June 30, 2020

• 175 patients presented with xenobiotic ingestion. But 19 patients were enrolled
• Physostigmine arm: 9 (47%)
• Lorazepam arm: 10 (53%)

Antimuscarinic agent ingested

• Diphenhydramine: 16 (84%)
• Dicyclomine: 1 (5%)
• Doxylamine: 1 (5%)
• Hyoscyamine: 1 (5%)

Proportion of subject with delirium by CAM-ICU

Prior to first bolus (p >0.99)

• Lorazepam arm: 9/10 (90%)
• Physostigmine arm: 9/9 (100%)

After 1^st bolus (p=0.01)

• Lorazepam: 10/10 (100%)
• Physostigmine: 4/9 (44.4%)

End of 4 hr infusion (p <0.001)

• Lorazepam: 10 (100%
• Physostigmine: 2 (22.2%)

No adverse events noted in both group

Conclusion

• Although this is a small study, it showed that physostigmine is better than lorazepam in treating antimuscarinic delirium and agitation.
• This study provides additional support to the finding from a prior retrospective study (Bruns MJ et al. Ann Emerg Med. 2000;35(4):374-381), which also showed the benefits of physostigmine over benzodiazepines in the management of antimuscarinic overdose associated delirium.

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• Prior studies have shown that ethnic minorities have lower levels of stroke knowledge and lower penetrance of public health stroke education.
• A recent study looked at whether patients’ language preference affects acute ischemic stroke care metrics.
  • 3190 stroke patients at an urban Comprehensive Stroke Center, where 300 (9.4%) had a non-English preferred language
  • They found no difference in:
    • Time from symptom discovery to ED arrival (128 min vs. 161 min for patients with English preferred language, p=0.68)
    • Arrival by EMS (65% vs. 61.3%, p=0.21)
    • Door-to-imaging time (55 min vs. 60 min, p=0.33)
    • Door-to-needle time for thrombolysis (51 min vs. 53 min, p=0.69)

Bottom Line: Patients' language preference does not appear to affect the efficiency of acute ischemic stroke care, especially at experienced high volume stroke centers. 

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PEEP in the Intubated Obese Patient

• Obesity has numerous adverse effects on the respiratory system, most notably a reduction in lung volumes.
• The reduction in lung volumes (i.e., FRC) often result in airway closure and atelectasis.
• The application of PEEP in the mechanically ventilated patient helps maintain alveolar patency by preventing derecruitment.
• Importantly, the typical initial PEEP setting of 5 cm H2O is insufficient for many ventilated obese patients.
• Pearl: In the ventilated obese patient start with an initial PEEP of 10-15 cm H2O.

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Opioid Conversion Updates

Updated in 2018, some clinicians are unaware of the changes to the opioid conversion tables.

When converting between opioids, it is important to remember the following steps:

1. Determine the patient’s level of pain and current response to therapy.
2. Calculate current opioid requirement.
3. Convert the opioid using table above.
4. ASSESS! Combine Steps 1-3 to determine what is most appropriate clinically.  If the patient is suffering from severe pain, using the calculated dose may be appropriate.  If the patient is requesting a switch but is otherwise pain controlled, consider a general dose reduction of 25-50% in the new opioid.
5. Monitor the patient for efficacy and side effects.

While online calculators can be helpful, opioid conversions should be done thoughtfully with a full patient assessment to determine the correct conversion for the individual patient.

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Several studies have described factors associated with peri-intubation cardiac arrest in the adult population. Factors such as pre-intubation hypotension, elevated BMI, and elevated shock index (HR/SBP) have been associated with cardiac arrest following intubation in adult ED patients. Given the differences in anatomy and physiology in children, one may expect risk factors for peri-intubation cardiac arrest to differ in children.

A number of studies have examined factors associated with peri-intubation cardiac arrest in the pediatric population, but these have remained limited to the inpatient setting. These studies have found that, in hospitalized and PICU patients, the factors of hemodynamic instability, hypoxemia, history of difficult airway, pre-existing cardiac disease, and higher number of intubation attempts are associated with peri-intubation cardiac arrest. A paucity of literature exists on this airway complication in pediatric ED patients.

Pokrajac et al. provide the first study on risk factors for peri-intubation cardiac arrest in pediatric ED patients. These authors conducted a retrospective nested case-control study of pediatric patients (ages <18 years) who presented to a tertiary children’s hospital in San Diego from 2009-2017. Cases included patients who had a cardiac arrest within 20 minutes after the start of endotracheal intubation. Authors selected a number of predictors to examine, including age-adjusted hemodynamic variables, capillary refill, pulse oximetry, patient characteristics, intubation-related factors, and pre-intubation interventions.

The authors found the following:

-       Demographic characteristics:

o   Patients with peri-intubation cardiac arrest were significantly younger (<1 year of age), shorter, and more likely to have history of preexisting pulmonary disease.

-       Incident characteristics:

o   Patients with peri-intubation cardiac arrest were more likely to have:

       -Low or unobtainable SBP or DBP

       -Delayed capillary refill time

       -Low (<92%) or unobtainable pre-intubation SpO2

        -More than 1 intubation attempt than controls

        -No paralytic or sedative agent prior to intubation

o   Patients with peri-intubation cardiac arrest were NOT more likely to have increases in age-adjusted HR or pediatric shock index in comparison to controls.

o   The strongest clinical predictor for peri-intubation cardiac arrest was pre-intubation hypoxia or unobtainable SpO2. This fact is supported by children’s increased metabolic rate and thus increased oxygen consumption. This physiologic finding explains the shorter amount of time it takes children to develop acute hypoxia, particularly in the peri-intubation setting.

Bottom line: If planning to intubate a pediatric patient in the ED, keep in mind that pre-intubation systolic or diastolic hypotension, delayed capillary refill time, multiple intubation attempts, and hypoxia in particular may increase the risk for peri-intubation cardiac arrest. Consider providing apneic oxygenation to minimize hypoxemia prior to intubation.

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Ethanol exposure among young children can result in significant morbidity. Infants and young children can be exposed to ethanol in many different ways: exploratory ingestion, mixed in formula-both intentionally and unintentionally, etc. 

A recently published study used national poison data system to characterize the ethanol exposure among infants < 12 months of age.

Results:

Between 2009-2018, 1,818 ethanol exposures among infants were reported. Oral ingestion was the most common (96.7%; n=1738). Annual number of ethanol exposure increased by 37.5% each year. 

Exposure site

• Residence: 96.7% (n=1,758)
• Public are/workplace or school: 1.6% (n=29)

Age

• 0-2 months: 16.3% (n=296)
• 3-5 months: 19.6% (n=357)
• 6-8 months: 18.8% (n=341)
• 9-11 months: 45.3% (n=824)

Clinically significant effects

• Coma: 20
• Hypoglycemia: 16
• Respiratory depression: 15
• Seizures: 13
• Hypothermia: 9
• Cardiac arrest: 4
• Respiratory arrest: 3
• Death: 5

563 infants (31%) were evaluated at hospital

38% (n=214) of the exposures were hospitalized

0-5 months of age 

• higher odds of admission: non-critical (OR: 2.35, 95% CI: 1.41-3.92) or critical care unit (OR: 2.39; 95% CI:1.5-3.79)
• higher odds of serious outcome (OR: 4.65; 95% IC: 3.18-6.79)

Conclusion

Ethanol exposure among infants is increasing each year and associated with serious clinical effects.  

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A 25 year old athlete presents to the ED with right anterior shoulder pain.

Pain radiates into proximal biceps.

It is worse with heavy lifting and especially “pulling” exercises at the gym.

How do we evaluate for biceps tendonitis?

1. Tenderness to palpation in the bicipital groove
2. Speed’s test
3. Yergason’s test

Pathology is often the long head of the biceps

https://physioworks.com.au/wp-content/uploads/2019/12/biceps-tendonitis.jpg

Start by palpating this area and attempt to reproduce the discomfort

Speed’s test

• Arm is supinated and extended and elevated against examiner’s  downward resistance
• https://youtu.be/N00gA4Pvsbw

Yergason’s test

• Arm is placed to patient’s side, in pronation and flexed to 90 degrees at elbow
• Patient attempts to supinate and externally rotate arm against resistance
• https://youtu.be/rQ2Mp6aSi88

To determine if the child is prepubescent, look for the lack of pubic hair, clitoral size, configuration of the hymen, breast development, and axillary hair growth. A Tanner stage of 1 would be consistent with prepuberty.

The proper positioning for the physical exam will allow the child to be comfortable and the examiner to obtain an adequate view including up to one-third of the vagina.

If the child is small enough, they can lay in the parent’s lap. For a larger child, you can have the parent sit in the bed with the patient or stand near the child’s head. Engage child life if available.

The frog leg position with gentle downward and outward traction of the labia at the 5- and 7-o’clock positions provides the optimal view.

The knee to chest position is helpful when further evaluation is needed.

A rectovaginal exam is useful for evaluation of masses or foreign body only and is not routinely needed. Place the examiner’s little finger in the rectum and the other hand on the abdomen and palpate.

The use of a vaginal speculum is rarely needed in prepubertal children; if it is needed, perform the exam under anesthesia.

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Summary

Our group performed a meta-analysis to assess whether it is safe to infuse vasopressor through peripheral venous catheters.  We identified 9 studies with a total of 1835 patients.  The prevalence of complications among the pooled patient population was 9%.  Up to 96% of the complications was extravasation and almost no complications required any treatment.

A few studies reported safe infusion of norepinephrine up to 0.1 mcg/kg/min for up to 24 hours.

In exploratory meta-regression, catheter size 20 or larger was negatively associated with the rate of complications.

We also observed that studies that were published within the past 5 years reported significantly lower rate of complications from older studies.  This suggested that with careful planning and monitoring, it is safe to start vasopressor through peripheral IV.

Limitation

most of the included studies were observational. No studies had enough power to statistically analyze any variables that could predict complications.

Bottom line: we should start vasopressor as soon as indicated, if we have good, reliable IV access.

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• Migraine is the 2nd most common neurologic disorder after tension headache and accounts for more disability than all other neurologic disorders combined.
• Diagnosis is clinical and defined by at least 5 episodes of headache that meet the following criteria:
  • Duration of 4 to 72 hours (when untreated or unsuccessfully treated)
  • At least 2 characteristics: unilateral, pulsating, moderate-to-severe pain intensity, aggravated by physical activity
  • Accompanied by at least 1 symptom: nausea, vomiting, photophobia, phonophobia
• Aura symptoms must be fully reversible and may be visual, sensory, speech/language, motor, brainstem, or retinal.
• Early treatment while the headache is still mild include NSAIDs followed by triptans.
  • Opioids and barbiturates are not recommended due to adverse effects and risk of dependency.
• Preventive treatment is recommended for patients who have at least 2 migraine days per month and whose lives are adversely affected.
  • Common therapies include antihypertensive agents (e.g. propranolol), antidepressants (e.g. amitriptyline), anticonvulsants (e.g. topiramate, valproate), and calcium-channel blockers (flunarizine).

Bottom Line: Migraine is a common and debilitating condition that benefits from early treatment. Consider initiating preventive therapy for patients who experience at least 2 migraine days per month and adverse effects despite treatment.

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What is the cause of Mad honey poisoning?

Grayanotoxin

Grayanotoxin is a neurotoxin that is found in honey contaminated with nectar of Rhododendron plants. It binds to activated/open neuronal sodium channels and prevents inactivation of sodium channels. Case reports of mad honey poisoning is often reported in the eastern Black Sea region of Turkey. Commercial honey producers frequently mix honeys from multiple sources to decrease the grayanotoxin contamination.

Mad honey poisoning is rarely fatal and generally resolves within 24 hours. Commonly reported symptoms include dizziness, weakness, impaired consciousness/disorientation, excessive perspiration, nausea/vomiting, and paresthesia. In severe intoxication, patients can experience complete AV block, bradycardia/asystole, hypotension, and syncope. 

Management is primarily supportive with atropine and IV fluids.

As the number of COVID-19 cases rises worldwide, prehospital and emergency department healthcare workers remain at high risk of exposure and infection during CPR for patients with cardiac arrest and potential SARS-CoV-2. 

Existing evidence supports similar cardiac arrest outcomes in airways managed with a supraglottic airway (SGA) compared to endotracheal intubation (ETT).¹  It is generally accepted that the best airway seal is provided with endotracheal intubation + viral filter, but how well do SGAs prevent spread of aerosols? 

In CPR simulation studies:

• Cuffed endotracheal tube + viral filter provides effective seal to prevent aerosolization during CPR.²
• SGA + viral filter decreases AP spread compared to facemask and compared to bag-valve mask ventilation during CPR.³
• Notable aerosolization is seen with SGAs, with no difference between AuraGain, I-gel, LMA Proseal, LMA Supreme, Combitube, or LTS-D.²

• Ventilating through an SGA + viral filter is likely better to limit spread of aerosolized particles than bag-valve mask ventilation.
• SGAs allow egress of aerosolized particles, although the amount and area of distribution in clinical practice is unclear, and endotracheal intubation with a cuffed endotracheal tube remains the best way to avoid ongoing aerosolized particle spread with chest compressions. 
• Appropriate PPE remains crucial to limiting healthcare workers' risk of infection and must be prioritized, even/especially in the management of patients in cardiac arrest. 

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The current COVID-19 pandemic and known aerosolized transmission has triggered many ED process changes, including the discouragement of utilizing nebulizers to administer inhaled bronchodilators such as albuterol for concern of spread. Historically, both patients and providers preferred the use of nebulizers as they are easier to use and the belief was that they were more effective than meterd dose inhalers. However, evidence based data has consistently shown that for both adult and pediatric patients that when MDI's are used WITH a spacer:

• There is NO significant difference in efficacy outcome.
• Nebs are associated with greater increase in tachycardia and tremors.
• Nebs are more costly overall.
• MDI's were associated with shorter ED stays and fewer hospital admissions for pediatric patients.

Albuterol:  2.5 mg nebulizer solution = 3-5 MDI puffs

Albuterol: 5 mg nebulizer solution = 5-10 MDI puffs

Ipratropium: 0.25 mg nebulizer solution = 2 MDI puffs

Ipratropium: 0.5 mg nebulizer solution = 4 MDI puffs

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Transfer of chemical from their original container to an unlabeled or different container (e.g. Gatorade bottle) is one of the common causes of unintentional poisoning. 

A retrospective study of National Poison Data System from 2007 – 2017 identified 45,512 cases of unintentional exposure/ingestion of chemicals contained in unlabeled/incorrectly labeled containers. 

Result

Annual reported cases increased from 3,223 in 2007 to 5,417 in 2017.

• Median age: 30 years (interquartile range: 6 – 53)
• Female: 52%

Most commonly involved products included

• Cleaning products: 38.2%
  • Bleach, 18.8%
  • Peroxides, 5.7%
  • Anionic cleaners, 4.6%
• Disinfectants: 17.3%
• Hydrocarbons: 5.0%

These exposures led to 

• ED visits: 9,369 (20.6%) 
• Hospitalization: 1,856 (4.1%) 
• Deaths: 23 (0.1%)

The majority of these exposures were non-toxic in nature (72%) but serious outcomes were noted in 4.4% of the cases, including 23 deaths.

Highest morbidity was associated with:

• Pesticides: 10.3%
• Prescription medications: 9.8%
• Herbicides: 7.6%

Deaths

• Hydrofluoric acid and herbicides accounted for 13 of 23 deaths (57%), followed by cleaning products (7/23).

Conclusion

• Transfer of a chemical to unlabeled/different container is a well-recognized risk factor of poisoning.
• Although small in number, the annual reported cases to the regional poison center are increasing.

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Ulnar Collateral ligament injuries of the elbow

Overhead throwing athletes are at risk of insufficiency and rupture of the ulnar collateral ligament (UCL) of the elbow

This can lead to valgus instability similar to what can occur in the knee

Overhead throwing places a significant valgus stress on the elbow

Though classically seen in baseball pitchers, may also be seen in javelin throwers and other high velocity throwing sports

In the acute setting may be seen after an elbow dislocation

History includes a “pop” and medial elbow pain following throwing activities

In cases of overuse injury, athletes will report a progressive loss of velocity, accuracy, and/or endurance with throwing.

The ulnar collateral ligament is the primary restraint to valgus stress from 30 to 120 degrees of flexion

One classic test for UCL instability is the milking maneuver

Patient may be sitting or standing

Patient’s forearm is supinated and elbow flexed at 90 degrees

A valgus force is applied by pulling the patient’s thumb while the examiner’s other hand stabilizes the elbow and palpates the medial joint line. 

Instability, pain or apprehension at the UCL is considered a positive test

https://www.youtube.com/watch?v=gbn24X_qqn0

N-acetylcysteine (NAC) is well known as the accepted antidote for acute acetaminophen (tylenol/paracetamol) overdose and is well studied for this indication.  While the literature base is not nearly as strong in other causes of acute liver failure, NAC is increasingly used in these scenarios as well.  In the emergency department in particular, the cause of fulminant hepatic failure is often not known.  NAC may have some protective benefit in non-acetaminophen acute liver failure.  Existing data do not show a mortality benefit to NAC in non-acetaminophen acute liver failure, but do show improvement in transplant-free survival.  The AASLD guidelines (last revised in 2011) do not comment on NAC in non-acetaminophen acute liver failure.  A common practice is to continue NAC until the INR is < 2 and AST/ALT have decreased at least 25% from their peak values.  

Patients in fulminant liver failure should also be strongly considered for transfer to a center that does liver transplant, if presenting to a non-transplant center.  The King's College criteria is the most commonly used prognostic score for determining need of transfer to a transplant center, but in addition to calculating a King's College score providers should generally consider consultation with a transplant hepatologist for any fulminant liver failure patient to discuss the risks/benefits of transfer for transplant evaluation.

Bottom Line: While not as strongly indicated as it is in acute acetaminophen induced liver failure, NAC should be considered in both non-acetaminophen liver failure and liver failure of unknown etiology.  In addition, strongly consider consultation with a transplant hepatologist in any case of fulminant hepatic failure.

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