Many patients present to the ED with hypercarbic respiratory failure (i.e. COPD exacerbation, obesity hypoventilation syndrome etc.). Typically, our first line of treatment is the use of BiPAP, where we set an inspiratory pressure (IPAP) and an expiratory pressure (EPAP). The difference between these two pressures (as well as patient effort) determines the tidal volumes (and consequently minute ventilation) a patient receives in our attempts to help the patient “blow off CO2.”
If you are having trouble with continued hypercarbia despite the use of BiPAP, another NIPPV mode that can be trialed is Average Volume-Assured Pressure Support (AVAPS). With BiPAP the patient receives the same fixed IPAP no matter what, even if their tidal volumes are lower than what is needed. With AVAPS, the ventilator will self-titrate the IPAP and increase (or decrease) the IPAP to reach the tidal volumes that you set, increasing the odds the patient will achieve the minute ventilation you are trying to achieve.
(AVAPS is essentially a non-invasive version of PRVC)
Initial settings (ask your RTs for help!):
The supracondylar fracture is one of the most common pediatric fractures. It typically occurs due to a FOOSH injury and is a result of fracture through an area of high growth (and therefore weaker bone structure) in the pediatric distal humerus. Appearance on x-ray depends on the degree of displacement, however in cases without obvious displacement, providers must look for more subtle signs on x-ray. For example, a “sail sign” of the anterior fat pad and appearance of a posterior fat pad indicate a joint effusion and are suggestive of a fracture. However, there are often still equivocal x-rays in children with notable tenderness on exam, and failure to appropriately immobilize these fractures can result in pain and higher risk of injury resulting in displacement.
In 2021, Varga et al, looked into the ability to assess for supracondylar fractures with ultrasound. This prospective study evaluated 5 locations in the pediatric elbow for signs of fracture. Ultimately, this was able to identify more fractures than x-ray alone, and was a useful tool for equivocal cases. This is not an isolated study, but one of the most comprehensive, looking into ultrasound as a tool for supracondylar fracture identification.
It may be time to grab that ultrasound probe to look for fractures in pediatric patients with pain but an unclear elbow x-ray.
This study used the modified Brain injury Guidelines retrospectively to assess whether the guidelines would have saved transfers to their level one facility safely. They concluded the guidelines would have effectively prevented unnecessary mBIG 1 and mBIG2 transfers with no patient harm.
TABLE 1 - Modified Brain Injury Guidelines Radiologic Stratification, as per Kahn et al.
| mBIG 1 | mBIG 2 | mBIG 3 | |
|---|---|---|---|
| Skull fracture | No | Non-displaced | Displaced |
| SDH | ?4 mm | 4–7.9 mm | ?8 mm |
| EDH | No | No | Yes |
| SAH | ?3 sulci and <1 mm | Single hemisphere or 1–3 mm | Bihemisphere or >3 mm |
| IVH | No | No | Yes |
| IPH | ?4 mm | 4–7.9 mm | ?8 mm or multiple |
EDH, epidural hematoma; IPH, intraparenchymal hemorrhage; IVH, intraventricular hemorrhage; SAH, subarachnoid hemorrhage.
A recent study attempted to investigate the relationship between a history of strength training with symptomatic and structural findings of knee osteoarthritis (OA).
For comparison, previous studies have shown that duration of football participation increases risk of radiographic knee OA.
Methods: Retrospective, cross-sectional multicenter study
2,607 participants without OA. Community population. 44% male. Mean age 64.3 years. Mean BMI 28.5.
Strength training (via self-administered questionnaire) defined as those exposed (n=1789 ) and not exposed (n=818). If exposed, groups were divided into low, medium and high.
Outcomes were 1) Radiographic OA. 2) Symptomatic radiographic OA. 3) Frequent knee pain
Results: Strength training at any point in life vs no strength training was associated with lower incidence of all outcome measures:
Odds ratio1) 0.82, 2) 0.83 and 3) 0.77.
Conclusions: Strength training is beneficial for future knee health
However, when separated by groups (low, medium and high), only the high-exposure group had significantly reduced odds of less frequent radiographic OA, symptomatic radiographic OA, and frequent knee pain.
Findings were similar for different age ranges
The association between strength training and less frequent radiographic OA, symptomatic radiographic OA, and frequent knee pain was strongest in the older age groups.
This really interesting study suggests that the classic site of CPR “in the middle of the chest” may actually not be the ideal place to perform CPR. Previous imaging studies demonstrate that the ventricles are primarily beneath the lower third of the sternum and that standard placement of CPR compressions may deform the aortic valve, blocking the LVOT, and theoretically limiting perfusion of the coronaries and brain.
This study compared a standard CPR group with those undergoing TEE-guided chest compressions to avoid aortic valve compression. Those in the non-AV compression group had significantly increased likelihood of ROSC, survival to ICU, and higher femoral arterial diastolic pressures. However, there was no difference in long-term outcomes or end-tidal CO2.
Summary: Avoiding AV compression during CPR significantly improved the chance at ROSC in adult OHCA, but this small observational study did not show any difference in long term outcomes when compared to standard practice. Lowering the point of chest compressions in CPR to the lower third of the sternum may be beneficial.
Do you have a patient with a finger injury or infection, or possibly a retained foreign body?
Try placing the hand in a water bath and use a linear ultrasound probe for evaluation. If there is an open wound, use a sterile ultrasound probe cover.
With ultrasound guidance, you can observe dynamic finger movements and identify areas that may require abscess drainage.
In this Scandinavian study looking at 2,362 head injury patients on oral anticoagulants, the authors found only 5 cases of delayed hemorrhage and none of the five underwent neurosurgery. The authors concluded:
“In patients with head trauma, on oral anticoagulation, the incidence of clinically relevant delayed intracranial hemorrhage was found to be less than one in a thousand, with detection occurring four days or later after initial presentation.”
It would appear based on this study and others that it is safe to discharge these patients with a normal head CT and giving strict return precautions for headache, nausea, vomiting or other changes.
Histamine is present in mosquito saliva contributing to itch with bites, however, certain populations – including children – can experience an exaggerated reaction. Skeeter syndrome is a large, localized inflammatory reaction secondary to a mosquito bite that presents with warmth, swelling, and itching. There can occasionally be associated lymphadenopathy and fever as well. The rapid onset is what best differentiates it from cellulitis. Treatment is primarily symptomatic in nature, focused on relieving itch, with antihistamines and topical therapy. There may also be a role for prophylactic antihistamine usage at times when mosquito bites will be unavoidable in a patient known to have developed Skeeter syndrome previously. Other patients who may be affected include those with immunologic and autoimmune phenomena, those with underlying atopy, outdoor workers with frequent exposure, and those with new exposure to indigenous mosquitos.
Take Home: Consider insect (mosquito bite) when evaluating for cellulitis/infection in pediatric patients, with impressive skin findings but otherwise unremarkable exams. They present with rapid onset and itching instead of pain. This can be especially prominent in periorbital and auricular presentations.
Title: Basics of Sleep Physiology and Architecture
By: Youssef Annous, MD
Sleep is integral for physical and mental health and performance. Sleep is extremely well conserved among species. All mammals need sleep to survive.1 A single sleep cycle typically lasts anywhere between 90 and 120 minutes and is broken down into two phases2:
Non-Rapid Eye Movement sleep
Stage 1 (Light Sleep)
This is the lightest form of sleep and the easiest to wake up from. During this stage, it is normal to experience muscle twitching and the sensation of drifting in and out of consciousness. This stage lasts approximately 5 minutes in the beginning of sleep and comprises around 5% of total sleep duration.2
Stage 2 (Light Sleep)
During this stage, you are likely to begin experiencing decrease in body temperature, heart rate (HR), blood pressure (BP) and respiratory rate (RR). Electroencephalography (EEG) during this phase of sleep would show sleep spindles and K complexes.2 These findings have been linked to memory consolidation.3
Stage 3 (Deep Sleep)
This is the deepest stage of sleep. During this phase, body temperature, HR, BP, and RR are at their lowest. This is the most restorative stage of sleep. It is essential for immune health, cardiovascular health, tissue repair, bone growth, and muscle recovery.2 It is also when growth hormone (GH) is at its highest. Physiological (e.g. illness) or psychological (e.g. anxiety) stressors can negatively impact this stage. We experience less deep sleep as we age.4
Rapid Eye Movement (REM) sleep
This stage of sleep is characterized by rapid eye movement, abundance of dreaming and heightened brain activity. During REM, there is total body paralysis with exception of ocular and respiratory muscles. It is theorized that your body is paralyzed during this stage to protect you from dream enactment. You experience more REM the longer you sleep. REM has been shown to be essential for memory consolidation, cognitive function, mood regulation and for coping with stress. This stage is particularly compromised by sedatives including but not limited to alcohol, benzodiazepines, and tetrahydro-cannabinoid (THC). Several studies in animals and humans showed that even modest REM sleep deprivation can result in increased mortality. 2,5,6
All sleep stages are extremely essential. Be careful of self-medicating with sleep aids such benzodiazepines or alcohol as this can be detrimental for your health. In later UMEM pearls, we will discuss protocols, supplements and behavioral ways to improve each stage of sleep for better mental and physical health.
This Delphi study and companion editorial highlight current thought on frailty screen in emergency department patients. Key takeaways are:
Emergency departments should be instituting procedures that incorporate screening older patients for frailty. These references are a good starting point.
On exam, assess for facial instability and airway patency. CT scan is the imaging of choice. The higher the number, the more complex the fracture, the more unstable and the more difficult the airway managment will be. Look for open lacerations or blood in the sinuses and treat with antibiotics if these are found. Consult ENT or plastics urgently for further management.
The reference is a nice review of these fractures
A recent study in Annals of EM investigated the use of topical Diclofenac in the treatment of lower back pain.
Small studies have shown topical NSAIDs to be effective for single joint OA and tendinopathies.
Currently, NSAIDs are first-line treatment for ED patients with acute low back pain.
Theoretically, topical NSAIDs deliver medications directly to the injured tissue while minimizing systemic side effects.
-Topical NSAIDs provide similar concentrations of the drugs in muscle tissue but much lower plasma concentrations than oral formulations
Design: Randomized, double-blind, placebo-controlled trial.
ED patients aged 18 to 69 years with non-radicular, non-traumatic acute lower back pain.
Screened 3,281 and enrolled 198.
Study groups:
Patients received 2 days of meds. Follow up by phone at 2 and 7 days.
Investigators used the RMDQ score to measures pain and functional impairment.
Results: At the 2 day follow-up, all 3 groups showed an improvement in the mean RMDQ score compared to baseline as expected.
Participants had a mean RMDQ improvement of 10.1 in the ibuprofen group, 6.4 in the diclofenac gel group, and 8.7 in the ibuprofen + diclofenac gel group.
At the 7-day follow-up, participants had a mean RMDQ change compared to baseline of 12.2 in the ibuprofen group, 9.5 in the diclofenac group, and 10.7 in the ibuprofen + diclofenac gel group.
Conclusion: This study does not support the use of topical diclofenac among patients who can otherwise tolerate oral ibuprofen.
Because the study did not compare placebo gel to topical Diclofenac, we cannot infer whether topical medication is helpful for treatment in acute lower back pain in those patients who may not be able to take NSAIDs.
This very small study looked at the utility of using IV contrast media to enhance abdominal sonography in identifying injuries in blunt abdominal trauma patients. The comparison was CT scanning of the abdomen to identify injuries. The study concluded:
“With the addition of contrast and careful inspection of solid organs, abdominal sonography with contrast performed by the emergency physician improves the ability to rule out traumatic findings on abdominal CT. CEUS performed by emergency physicians may miss injuries, especially in the absence of free fluid, in cases of low-grade injuries, simultaneous injuries, or poor-quality examinations.”
To me, this is a limited study and the technique is not ready for wide spread use but further study is warranted.
There is a growing trend toward the development of specialty-specific emergency services, such as Geriatric or Oncologic EDs.
Will this trend continue? Is the segmentation of emergency care in our future? The author of this article opines that the answer depends on future outcomes research in this area.
Historically, guideline recommendations have been to use a transfusion threshold of hemoglobin < 7 g/dL for patients unless they are a) undergoing orthopedic surgery or b) have cardiovascular disease (CVD).
Applefeld et al conducted a meta-analysis in 2018 which suggested that restrictive (i.e. lower hemoglobin trigger, typically 7-8) transfusion targets lead to worse outcomes in CVD patients than liberal (i.e. higher hemoglobin trigger, typically 9-10) targets, and those authors have updated this analysis to include data from newer trials. Interestingly, the conclusion remains similar: that when you look at the larger studies on restrictive vs liberal transfusion targets, CVD plays an important role, as patients with CVD tend to do better with liberal targets, and patients without CVD tend to do better with restrictive targets. Of note, CVD is variably defined in these studies, and sometimes limited only to active Acute Coronary Syndromes, and other times refers to all patients with acute or chronic CVD. However, according to their analysis, the aggregated data suggests that we should continue having higher transfusion targets in patients with CVD, and perhaps even more in the 9-10 range, as opposed to the goals of 7 or 8 which are common.
Bottom Line: We will likely continue to see different transfusion targets recommended for patients with cardiovascular disease (CVD), and may even see guideline and blood bank recommendations raise the target for these patients more into the 9-10 range, or expand this group to include chronic CVD. This would mean a substantial increase in recommended RBC transfusions, and as emergency physicians it is important for us to monitor these recommendations, especially since transfusions are not harmless and raising hemoglobin thresholds could lead to complications that are difficult to measure in the literature.
Starting a study? Frame your research question in the PICO format:
Patients (consider severity of presentation, setting, demographics)
Intervention (either something you propose or something in use)
Comparison (another group, the same group without intervention, or a benchmark)
Outcome (a measurement)
This classic format has been used to evaluate studies, as in Journal Club (by our esteemed Dr. Wilkerson), as a literature search tool, or by the Cochrane review.
Starting with a PICO research question can help you narrow your focus and maintain it.
In this podcast, the concept of vasopressor use in hemorrhagic shock is discussed. Key take away points:
This was a cross sectional study examining insurance data to determine if there is seasonality related to ED visits and psychiatric hospitalizations related to suicidality.
Suicidality includes both suicidal ideation and suicide attempts (but not suicide). One survey showed that up to 12% of US adolescents reported serious thoughts of suicide. This study included 73,123 patients where 19.4% were direct inpatient admissions and 80.6% were ED visits, 44% of whom were subsequently admitted.
Metrics for suicidality in 10-18 year olds peaked in April and October with a nadir in June. Incidentally, in the Spring of 2020 when US schools closed due to COVID, there was a decrease in both ED visits and hospitalizations with April and May having the lowest rates across the study period.
School is believed to increase stress with risk factors such as bullying and peer pressure, academic and extracurricular stressors and poor sleep hygiene.
Bottom line: There has been an increase in adolescent suicidality over the recent years, many of whom present to the ED for evaluation. More mental health resources are needed, especially during the school year.
Maternal morbidity continues to increase in the US with a mortality rate in 2021 of 39.2 deaths/100,000 live births. There has been an intense focus on training and quality improvement within hospitals, but not much has changed in the prehospital education arena. This study aimed to quantify the complications encountered by EMS clinicians.
In the 2018-2019 EMS dataset used, there were a total of 56,735,977 EMS activations which included 8641 out of hospital deliveries, 1712 documented delivery complications and 5749 records of newborns.
1% of the out of hospital deliveries had a documented complication for the mother. Of these complications, 94% were for hemorrhage, 6% for abnormal presentation, 0.2% for shoulder dystocia, and 0.4% for nuchal cord.
Few patients had medications given, including 0.4% receiving oxytocin. no patients received prehospital blood transfusion or TXA. Of note, in the years since this data was obtained, TXA and whole blood have started to appear on more medic units, but it is still not necessarily commonplace.
Bottom line: While still rare, prehospital delivery does occur and EMS should be prepared for any possible complications. Medical directors should look at their jurisdictional/state protocols to see if oxytocin/TXA or whole blood should be included (if not already available). EMS clinicians should be educated on up to date management of OB emergencies.
