Category: Critical Care
Clinical Pearls for Variceal Hemorrhage
-lower mortality with “restrictive” (Hgb 7-9 g/dL) rather than liberal strategy
-antibiotic “prophylaxis” reduces mortality
-no need to correct INR with FFP
-vasoactives (i.e. octreotide, somatostatin, terlipressin) alone may actually control bleeding
-for your ICU boarders...if persistent or severe rebleeding (despite endoscopic therapy), rescue TIPS is therapy of choice (call IR)
Zanetto A, Shalaby S, Feltracco P, et al. Recent advances in the management of acute variceal hemorrhage. Journal of Clinical Medicine. 2021;10(17):3818.
Category: Pharmacology & Therapeutics
Keywords: Calcium, cardiac arrest (PubMed Search)
Calcium is commonly administered during cardiac arrest, but there is little data to support or refute its use. The Calcium for Out-of-Hospital Cardiac Arrest trial was a randomized, double-blind, placebo-controlled parallel group study conducted in Denmark. Their EMS system responds to all cardiac arrests with an ambulance and a physician-manned mobile emergency care unit.
Adult patients were included if they had out of-of-hospital (OOH) cardiac arrest and received at least 1 dose of epinephrine. Exclusion criteria were traumatic arrest, known or suspected pregnancy, prior enrollment in the trial, receipt of epinephrine from an EMS unit not in the trial, or a clinical indication for calcium during the arrest (i.e. hyperkalemia or hypocalcemia).
Patients received 735mg calcium chloride dihydrate (5 mmol CaCl –US standard product is 1000mg) or saline control immediately after the first dose of epinephrine. A second dose was administered after the second dose of epinephrine if cardiac arrest ongoing. Teams were blinded to the treatments. The primary outcome was ROSC for at least 20 minutes.
397 patients were randomized (197 calcium, 200 saline). The average age was 68 years old, 70% were male, and over 80% of the cardiac arrests occurred at home, 60% witnessed arrests, and 82% received bystander CPR. Only 25% were in a shockable rhythm. The time to first epinephrine and study drug was approximately 17 minutes and over 70% received two doses.
ROSC rates were low and not statistically different between groups, 19% in the calcium group vs 27% in the saline group. There was no difference in survival to 30d or neurologic function. In the patients who did achieve ROSC in the calcium arm, 74% had hypercalcemia.
Bottom Line: The routine use of calcium in out-of-hospital cardiac arrest is not recommended.
Vallentin MF, et al. Effect of intravenous or intraosseous calcium vs saline on return of spontaneous circulation in adults with out-of-hospital cardiac arrest. JAMA. Published online November 30, 2021. doi:10.1001/jama.2021.20929
Keywords: peds ortho, calcaneus, stress injury (PubMed Search)
Smith JM, Varacallo M. Sever Disease. [Updated 2021 Jul 18]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK441928/
Keywords: Elbow, fracture, radiology (PubMed Search)
Presentations of Fracture in Nursemaids Elbow
Study group: Visits by children younger than 10 years, with a diagnosis of radial head subluxation at 1 of 45 pediatric EDs from 2010 to 2018.
Retrospective cohort study of 88,466 ED visits for radial head subluxation
Outcome: Missed fracture (return visit for upper extremity fracture within 7 days of the index visit).
Median patient age was 2.1 years,
59% of visits were by female patients,
60% of cases occurred in the left arm.
Radiography was performed at 28.5% of visits (Range 19.8% to 41.7%.)
Extremity fractures were observed in 247 cases, representing 0.3% of the cohort.
The odds of missed fracture were higher in:
Only 0.3% of children with a diagnosis of radial head subluxation subsequently received a diagnosis of an upper extremity fracture within 7 days of the index visit.
Missed fractures were commonly about the elbow such as a supracondylar fracture. However, this study also found a significant proportion of missed fractures in other locations (e.g. shoulder, wrist), highlighting the importance of a careful physical examination, and the limitations of localizing pain in younger children.
Recurrence was common, and the risk of recurrence decreased with increasing age at first presentation. Overall, radial head subluxation recurrence was 8.7% after the first visit VERSUS 12%-13% in children younger than 2 years. THese patients are likely to return to the ED with a recurrence within 2 years. These findings should help inform anticipatory guidance to parents regarding the risk of recurrence based on their child’s age.
Category: Critical Care
Myocarditis is a potentially fatal inflammatory disorder of the heart. Viral infection is the most common cause but can also result from toxic, autoimmune, or other infectious etiologies. Complications include life-threatening dysrhythmias, heart failure, and fulminant myocarditis. Typically affects young patients (20-50 years old).
ED management pearls
Gottlieb, Michael et al. "Diagnosis And Management Of Myocarditis: An Evidence-Based Review For The Emergency Medicine Clinician". The Journal Of Emergency Medicine, vol 61, no. 3, 2021, pp. 222-233.
Keywords: orthopedics, upper extremity fractures, playgrounds (PubMed Search)
Curnow H and Millar R. Too far to fall: Exploring the relationship between playground equipment and paediatric upper limb fractures. Journal of Pediatrics and Child Health. 2021.
Category: Critical Care
Keywords: OHCA, IHCA, targeted temperature management, therapeutic hypothermia, postcardiac arrest (PubMed Search)
Fever has long been understood to be associated with worse outcomes in patients post-cardiac arrest. Whether ascribing to the goal of 33-34°C, 36°C, or simply <38°C, close monitoring and management of core temperatures are a tenet of post-cardiac arrest care.
A recently published study compared the effectiveness of several methods in maintaining temperatures <38°C…
Maintenance of temp <38°C:
Mean change in temp from baseline:
Keywords: Elbow, dislocation, instability (PubMed Search)
The classic mechanism for nursemaids elbow is axial traction on a pronated forearm and extended elbow.
The force allows a portion of the annular ligament to slip over the radius.
Consider this diagnosis with other mechanisms of injury especially if the exam is not suggestive of fracture.
Suspect in a patient in minimal distress with arm held semi flexed and pronated.
A recent retrospective study looked at other mechanisms of injury.
69 subjects with a median age of 2.5 years
The most common mechanisms of injury were fall (57%), direct hit to the elbow (16%), and rolling over (7%).
Some studies note the left elbow is more commonly involved but this is likely due to most guardians being right-handed, thereby holding the child’s left hand
Li N, Khoo B, Brown L, Young T. Nonaxial Traction Mechanisms of Nursemaid's Elbow. Pediatr Emerg Care. 2021 Jun 1;37(6)
Keywords: drug reaction, toxicity, neurotoxicity, antibiotics (PubMed Search)
Bottom Line: Recognition of antibiotic associated neurotoxicity reduces unnecessary workup and serious adverse effects.
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Category: Critical Care
Keywords: Hypothermia, Cardiac Arrest, TTM (PubMed Search)
The debate around post-arrest management recently has revolved around whether therapeutic hypothermia should go cold, or LESS cold. But what if we went MORE cold? While recent TTM trials have compared temps such as 33 to 36 and 33 to 37.5 or less, a recent trial called CAPITAL CHILL looked at 34C vs 31C. There is a solid physiologic basis for cooling post-arrest patients, so do they do better if we lower their temp even further? Maybe we're not going cold enough with 33?
Bottom Line: No, 31C is not better than 34C for post-arrest patients. This study compared death and poor neurologic outcome at 180 days with 31 and 34C targets for post-arrest patients, and found no difference (in fact the 31C group did slightly, but not significantly, worse on the primary outcome, and worse on a few secondary outcomes).
While debate remains for 33 vs 36 vs afebrile, the literature does not currently support consideration of temps below 33.
Le May M, Osborne C, Russo J, So D, Chong AY, Dick A, Froeschl M, Glover C, Hibbert B, Marquis JF, De Roock S, Labinaz M, Bernick J, Marshall S, Maze R, Wells G. Effect of Moderate vs Mild Therapeutic Hypothermia on Mortality and Neurologic Outcomes in Comatose Survivors of Out-of-Hospital Cardiac Arrest: The CAPITAL CHILL Randomized Clinical Trial. JAMA. 2021 Oct 19;326(15):1494-1503. doi: 10.1001/jama.2021.15703. PMID: 34665203; PMCID: PMC8527358.
Category: Pharmacology & Therapeutics
Keywords: Kcentra, AC Reversal, Anticoagulant (PubMed Search)
Kcentra (four-factor prothrombin complex concentrate, 4f-PCC) is approved for the reversal of warfarin using a weight-based dosing strategy based on INR. However, since the approval of Kcentra, data has shown a fixed-dose strategy and use for direct-acting oral anticoagulants (DOAC) is appropriate. There are even recommendations to use a fixed-dose for DOACs in some situations. Utilizing a fixed-dose strategy can help with decreasing drug preparation/delivery times and costs.
Our institution now only uses a weight-based Kcentra dose of 50 units/kg for patients on DOACs with ICH or trauma-induced coagulopathy. All other patients receive a fixed-dose of Kcentra 1,500 units or 2,000 units based on anticoagulant and other criteria.
Below is a diagram summarizing our current dosing strategy for Kcentra at our institution.
DOAC=direct-acting oral anticoagulant (rivaroxaban, apixaban, and edoxaban)
Other points of interest at our institution:
Kcentra® [package insert]. CSL Behring, Marburg, Germany; 2013.
Tomaselli GF, et al. 2020 ACC Expert Consensus Decision Pathway on Management of Bleeding in Patients on Oral Anticoagulants: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2020 Aug 4;76(5):594-622.
University of Maryland Medical Center. 2021. Pre- and Peri-Procedural Management of Anticoagulation, Management of Bleeding in the Setting of Anticoagulation, Intracranial Hemorrhage, and Dilutional Coagulopathies. Internal guideline.
Keywords: T1DM, DKA, pediatrics (PubMed Search)
Incidence of T1DM is 1.93/1000 of youth <20 years old in the United States, with a bimodal distribution of onset. Onset peaks from ages 4-6 and again at puberty.
Prior to the development of DKA, diabetes often has an insidious onset with symptoms of polydipsia, polyphagia and polyuria with weight loss in children. It can also be asymptomatic.
When DKA is present, symptoms will include neurological manifestations (confusion, lethargy), GI symptoms (abdominal pain, nausea, vomiting), or respiratory abnormalities (Kussmaul respirations.) Polyuria and polydipsia are frequently present as well.
Diagnosis of DKA includes: serum glucose of >200 mg/dL, serum or urine ketones, and a pH <7.30 or bicarbonate <15 mEq/L.
DKA is classified as mild, moderate or severe:
Mild: pH 7.21-7.30, HCO3 11-15 mEq/L
Moderate: pH 7.11-7.20, HCO3 6-10 mEq/L
Severe: pH < 7.10, HCO3 <5 mEq/L
Initial treatment is 10 ml/kg of isotonic fluid bolus to a max of 500 ml, then reassess. Continue to replace fluids gradually to cover maintenance fluids as well as to treat dehydration. Do NOT bolus insulin. Rather, start a drip at 0.05-0.1 units/kg/hr. Continue insulin until acidosis has completely resolved. Once the serum glucose falls below 250 mg/dL, start dextrose to prevent hypoglycemia until the gap closes.
Cerebral edema can develop 4-12 hours after treatment has been initiated. Observe for change in mental status, posturing, decreased response to pain, cranial nerve palsy, bradycardia, or abnormal respiratory pattern. This is a clinical diagnosis! Although a head CT can be obtained, it is often negative and treatment with mannitol or hypertonic saline should be started as soon as there are clinical changes.
DKA has resolved when pH > 7.3 and HCO3 is >15.
Naga, O. (2020). Pediatric Board Sudy Guide: A Last Minute Review, 2nd Edition. Springer Nature Switzerland AG.
Dean, T. and Bell L. (2019). Nelson Pediatrics Board Review Certification and Recertification. Elsevier.
Keywords: pediatric fatality, poisoning, US (PubMed Search)
Substance use disorder contributes significantly to pediatric exposure/poisoning. There has been an increase in the opioid overdose deaths in the US, placing pediatric population to possible exposure. A retrospective study of fatal pediatric poisoning in the US was investigated using the National Violent Death Reporting System (NVDRS) from 2012-2017.
17 US states (AK, CO, GA, KT, MD, MA, NJ, NM, NC, OH, OK, OR, RI, SC, UT, VA, WI) reported to NVDRS from 2012-2017.
Age was limited to 0-9 years
1850 violent deaths were identified: n=122 (7%) were poisoning related
Most common exposure/etiology
Hunter AA et a. An examination of fatal child poisonings in the United States using the National Violent Death Reporting System (NVDRS), 2012–2017. Clin Toxicol. 2021
Category: Critical Care
Initial Mechanical Ventilation Settings for the Intubated Asthmatic
Long B, et al. Evaluation and management of the critically ill adult asthmatic in the emergency department setting. Am J Emerg Med. 2021;44:441-51.
Category: Critical Care
Keywords: Cardiogenic Shock, Milrinone, Dobutamine (PubMed Search)
Background: A cornerstone of therapy for cardiogenic shock is inotropic support with medications including dobutamine, epinephrine and milrinone. Few studies have examined these head-to-head and between dobutamine and milrinone (including only one RCT of 36 patients)
The investigators conducted a RCT of milrinone versus dobutamine for cardiogenic shock in a single quaternary care center cardiac ICU.
Inclusion: Patients over 18 with cardiogenic shock (largely clinical determination)
Exclusion: Out-of-hospital cardiac arrest, pregnancy, prior initiation of dobutamine or milrinone, or physician discretion.
Methods: 1:1 randomization stratified by affected ventricle (LV vs RV). Primary outcome was a composite of in-hospital death, resuscitated cardiac arrest, cardiac transplant, mechanical circulator support, nonfatal MI, TIA, stroke, or renal replacement therapy. Powered to detect a 20% improvement in this measure in the milrinone group (192 pts).
Results: 192 patients enrolled (96 in each arm). Average age was 70, 36% female, 90% LV dysfunction, 67% ischemic disease, 33% non-ischemic, average LVEF 25%, 68% on vasopressors. ICU admission to randomization was 23+/-92.6h for dobutamine and 17.6+/-50.6h for milrinone arms. 80% were SCAI class C shock.
Primary outcome for milrinone 49% versus dobutamine 54%, HR 0.9(0.69-1.19), p=0.47, death was the primary driver of the composite (37% vs 43%). Arrythmia requiring intervention was not different between groups (50% vs 46%). No difference in a host of other endpoints including AKI (92% vs 90%), RRT (22% vs 17%), HR, lactate, MAP, UOP, and creatinine.
Discussion: No significant differences observed in outcomes for patients with cardiogenic shock randomized to milrinone versus dobutamine. The trial addressed an important clinical question for management of cardiogenic shock and relied largely on clinical diagnosis for inclusion and likely reflected a somewhat broad range of patients. The trial was too small given observed treatment effects and few patients with RV failure. Notably, similar rates of adverse events observed in each group.
Many limitations for practice including a single specialized ICU setting, limited information on events leading to ICU admission including invasive or medical interventions during the index visit and no long term follow-up. Time to randomization, exclusion of cardiac arrest, and lack of reporting pre-ICU setting (ED, floor, cath lab) also significantly limits utility in an emergency setting.
Bottom Line: 192 patient single-center cardiac ICU-based trial shows no difference in composite or secondary endpoints between milrinone and dobutamine for cardiogenic shock, adds to a body of very limited RCTs comparing inotropes in cardiogenic shock but provides no practice changing evidence.
Mathew R, et al. Milrinone as Compared with Dobutamine in the Treatment of Cardiogenic Shock. N Engl J Med. 2021 Aug 5.
Keywords: ventriculoperitoneal shunt, neurosurgery (PubMed Search)
Ventriculoperitoneal (VP) shunts are common. Unfortunately shunt complications are also common!
There are 3 major categories of shunt complications:
Shunt series are helpful, but are NOT 100% sensitive. If you have a clinical concern for a shunt complication, make sure to involve neurosurgery.
For more reading:
Keywords: Concussion, sex differences, head injury (PubMed Search)
The total number of concussions tripled among female athletes aged 14 to 18 years during a 20-year period from 2000 to 2019.
Query of National Injury Surveillance System
Female athletes with sports-related concussions or closed head injuries who presented to the ED
In 14- to 18-year-old females the number of concussions increased from 9,000 in 2000 to 32,000 in 2019.
65% of all concussions among female athletes occurred in soccer, basketball, cheerleading, softball, and volleyball.
Association between an increase of 308.7 annual concussions per 10,000 annual female participants.
In a study of more than 80,000 teenage players across US high schools, female athletes are 1.9 times more likely to develop a sports-related concussion than are their male counterparts in comparable sports.
In boys, the most common way of becoming concussed was through direct contact with another player (50%)
In girls, the most common way of becoming concussed was after colliding with another object (ball/goalpost).
This mechanism may partly explain another finding: Boys were also more likely to be removed from play immediately after a suspected head injury than were girls
Category: Critical Care
Keywords: decompensated heart failure, hypertonic saline, furosemide (PubMed Search)
Settings & Designs: a meta-analysis of 11 randomized controlled trials among patients with fluid overload.
Patients: This meta-analysis included 2987 patients with acute decompensated heart failure.
Intervention: intravenous hypertonic saline + intravenous furosemide.
Comparison: intravenous furosemide
Outcome: all-cause mortality, hospital length of stay
· Hypertonic saline + furosemide treatment was associated with lower relative risk of mortality (RR 0.55, 95% CI 0.33-0.76%, P< 0.05, I-square = 12%).
· Hypertonic saline + furosemide treatment was also associated with 3.8 shorter hospital length of stay (mean difference = -3.38 days, 95% CI -4.1 to -2.4, P< 0.05, I-square = 93%).
· Sodium creatine also decreased about 0.46 mg/dl (mean difference, -0.46, 95% CI -051, -0.41, P<0.05, I-square 89%) for patients received both hypertonic saline and furosemide.
· Most studies only included patients with advanced heart failure (NYHA class IV, EF < 35%)
· For these patients with advanced heart failure, most studies infused 150 ml of 1.5%-3% saline. However, all studies used very high doses of furosemide (500mg -1000mg BID).
In patients with acute decompensated heart failure, a combination of hypertonic saline and intravenous furosemide was associated with improved outcomes, compared with a single therapy of furosemide.
Liu, Chang PhD, MD; Peng, Zhiyong PhD, MD; Gao, Xiaolan MD; Gajic, Ognjen MD; Dong, Yue MD; Prokop, Larry J. MLS; Murad, M. Hassan MD; Kashani, Kianoush B. MD, MSc, FASN, FCCP; Domecq, Juan Pablo MD. Simultaneous Use of Hypertonic Saline and IV Furosemide for Fluid Overload: A Systematic Review and Meta-Analysis, Critical Care Medicine: November 2021 - Volume 49 - Issue 11 - p e1163-e1175 doi: 10.1097/CCM.0000000000005174.
Keywords: seizure, status epilepticus, midazolam (PubMed Search)
This was a retrospective, noninferiority analysis looking at patients 14 years old and younger treated for nontraumatic seizures by EMS with a midazolam dose of 0.1 mg/kg (regardless of route). There were just over 2000 patients with a median age of 6 years included in the study. Midazolam redosing occurred in 25% of patients who received intranasal midazolam versus only 14% who received midazolam via intramuscular, intravenous, or intraosseous routes.
Bottom line: In the prehospital setting, intranasal midazolam at a dose of 0.1 mg/kg was associated with an increased need to redose compared to other routes. This dose may be subtherapeutic for intranasal administration.
Keywords: burr hole, trephination, subdural hematoma, epidural hematoma, herniation (PubMed Search)
Your patient presents with a large traumatic subdural hematoma with midline shift and clinical evidence of herniation. Your nearest neurosurgeon is several hours away, what do you do?
Initial resuscitation should follow ATLS. Treatment of intracranial hypertension and herniation includes elevating the head of bed, administering osmotic therapies, optimizing analgesia/sedation, and hyperventilation. If all measures have been exhausted and there is a delay to definitive neurosurgical intervention, an emergency department burr hole may be considered.
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