Category: Critical Care
Does This Patient Have Pericardial Tamponade?
Alerhand S, Carter JM. What echocardiographic findings suggest a pericardial effusion is causing tamponade? Am J Emerg Med. 2019; 37:321-6.
Keywords: Maintenance fluids, D5, NS, hyponatremia (PubMed Search)
Hyponatremia is the most common electrolyte abnormality in hospitalized patients, affecting approximately 15-30% of patients. Children have historically been given hypotonic maintenance IV fluids based off of theoretical calculations from the 1950s. Multiple studies have shown complications related to iatrogenic hyponatremia, including increased length of hospital stay, seizures and death.
The American Academy of pediatrics completed a systematic review and developed an updated clinical practice guideline:
Patient's age 28 days to 18 years requiring maintenance IV fluids should receive isotonic solutions with the appropriate amount KCl and dextrose.
Feld LG, Neuspiel DR, Foster BA, et al. Clinical Practice Guideline: Maintenance Intravenous Fluids in Children. Pediatrics. 2018;142(6):e20183083
Keywords: physostigmine, anticholinergic toxicity, adverse effects (PubMed Search)
Physostigmine is a cholinergic agent that can be administered to reverse delirium associated with anticholinergic toxicity. However, it is infrequenly used since the reports of cardiac arrest in patients with TCA overdose.
A recently published study reviewed 161 articles – involving 2299 patients – to determine the adverse effects and their frequency after the administration of physostigmine.
Adverse effects were observed in 415 patients (18.1%)
Specific adverse effects
Of 394 TCA overdose, adverse effects occurred in 14 patients (3.6%)
Arens AM et al. Adverse effects of physostigmine. J Med Toxciol. Feb 11. doi: 10.1007/s13181-019-00697-z. [Epub ahead of print] Review.
Category: Critical Care
Keywords: neutropenic fever, typhlitis, necrotizing enterocolitis, sepsis, septic shock (PubMed Search)
Neutropenic enterocolitis can occur in immunosuppressed patients, classically those being treated for malignancy (hematologic much more commonly than solid tumor). When involving the cecum specifically, it is known as "typhlitis."
It should be considered in any febrile neutropenic patients with abdominal pain or other symptoms of GI discomfort (diarrhea, vomiting, lower GI bleeding), and can be confirmed with CT imaging.
A recent study found that invasive fungal disease, most often candidemia, occurred in 20% of febrile neutropenic patients with CT-confirmed enteritis, a rate that increased to 30% if the patient was in septic shock.
1. Have a lower threshold for abdominal CT imaging in your patients with febrile neutropenia and abdominal pain/GI symptoms, especially if they are critically ill.
2. Consider addition of IV antifungal therapy if they are hemodynamically unstable with enterocolitis on CT.
Duceau B, Picard M, Pirrachio R, et al. Neutropenic enterocolitis in critically ill patients: Spectrum of the disease and risk of invasive fungal disease. Crit Care Med. 2019. [Epub ahead of print] doi: 10.1097/CCM.0000000000003687.
Keywords: Neck pain, radiculopathy (PubMed Search)
Spurling’s maneuver and modified Spurling’s maneuver aka neck compression test.
This maneuver is highly specific for the presence of cervical root compression
Can be used to reproduce radicular pain/symptoms.
Perform this maneuver with caution as it should not be performed in patients who have potential cervical spine instability.
Keeping the patient’s head in a neutral position pressing down on the top of the head. If this fails to reproduce the patient's pain, the test is repeated with the head extended, rotated and tilted to the affected side (the modified Spurling’s maneuver).
Reproduction of symptoms (limb pain or paresthesias) beyond the shoulder is considered positive. Neck pain alone is nonspecific and constitutes a negative test.
The test has a high specificity (0.89 to 1.00) but low sensitivity (0.38 to 0.97).
Meaning a positive test is helpful but a negative test does not rule out radicular pain.
This test should be used in conjunction with a thorough history and physical examination (strength, sensation and reflex testing)
Thoomes, Spine J 2018 Value of physical tests in diagnosing cervical radiculopathy: a systematic review.
Category: Critical Care
Management of Acute Variceal Bleeding
Boregowda U, et al. Update on the management of gastrointestinal varices. World J Gastrointest Pharmacol Ther. 2019; 10:1-21.
Keywords: older adults, CrCl, GFR, weight (PubMed Search)
Serum creatinine decreases with age with the decrease in lean body mass. However, the number of functioning glemeruli and kidney function decrease with age as well, making the creatinine an unreliable indicator of renal function in older adults.
The solution? Calculate the creatinine clearance (CrCl) (or GFR) for a more accurate assessment of the renal function. You can use simple equations such as the Cockroft-Gault equation which incorporate the body weight and age.
CrCl (mL/min) = (140-age) x lean body weight (kg) x (0.85 if female)
serum creatinine (mg/dL) x 72
Cockcroft DW, Gault H, Gault MH. Prediction of creatinine clearance from serum creatinine. Nephron. 1976;16(1):31-41. doi:10.1159/000180580.
Wiggins J, Patel SR. Aging of the kidney. In: Halter J, Ouslander J, Studenski S, et al., eds. Hazzard’s Geriatric Medicine and Gerontology. 7th edition. New York, NY: McGraw-Hill; 2017. http://accessmedicine.mhmedical.com/content.aspx?bookid=1923§ionid=144525776.
Category: Pharmacology & Therapeutics
Keywords: hypoglycemia, hyperkalemia (PubMed Search)
Scott NL, Klein LR, Cales E, Driver BE. Hypoglycemia as a complication of intravenous insulin to treat hyperkalemia in the emergency department. Am J Emerg Med. 2019;37(2):209-213.
Keywords: Methylene Blue (PubMed Search)
Most clinicians are familiar with use of methylene blue for the treatment of methemoglobinemia, as a urinary analgesic, anti-infective, and anti-spasmodic agent, or for its use in endoscopy as a gastrointestinal dye, but this compound also has a role as a rescue antidote in life threatening poisonings causing refractory shock states and other shock states.
Methylene blue should be considered when standard treatment of distributive shock fails.
Methylene Blue for Distributive Shock: a Potential New Use of An Old Antidote. Jang DH, Nelson LS, Hoffman RS. J Med Toxicol. 2013;9(3):242-9.
Methylene blue used in treatment of refractory shock resulting from drug poisoning. Fischer J. Taori G. et al. Clin Toxicol 2014 Jan;52(1) 63-65.
Calcium channel antagonist and beta blocker overdoses: antidotes and adjunct therapies. Graudins A, Lee HM, Druda D. Br J Clin Pharmacol. 2016 Mar 81(3):453-61.
A Review of Methylene Blue Treatment for Cardiovascular Collapse. Lo A, Jean CY, et al. Journal of Emerg Med. May 2014. Vol 46 (6): 670-679.
A Systematic Analysis of methylene Blue for Drug-Induced Shock. Warrick BJ, Tataru AP, Smolinske S. Clin Toxicol 2016 Aug;54(7):547-55.
Category: Critical Care
Keywords: OHCA, cardiac arrest, resuscitation, maternal cardiac arrest, pregnancy (PubMed Search)
Historically, there has been very limited data regarding the epidemiology of OHCA in pregnant females. Two recently-published studies tried to shed some light on the issue.
Both Maurin et al.1 and Lipowicz et al.2 looked at all-cause out-of-hospital maternal cardiac arrest (MCA) data in terms of numbers and management, in Paris and Toronto respectively, from 2009/2010 to 2014. Collectively, they found:
A few reminders from the 2015 AHA guidelines for the management of cardiac arrest in pregnancy:
Bottom Line: Although maternal cardiac arrest is relatively rare, survival in OHCA is lower than perhaps previously thought. Areas to improve include public education on the importance of bystander CPR in pregnant females, and appropriate physician adherence to PMCS recommendations, with decreased on-scene time by EMS in order to decrease time to PMCS.
Maurin et al. looked at documented out-of-hospital maternal cardiac arrest (MCA) in pregnant females ≥18 years old, in Paris from 2009 to 2014 and reported on some aspects of prehospital care. Prehospital management there includes activation of both a BLS (which usually arrives first) and ALS team, with a prehospital emergency physician being a member of the ALS team.
Lipowicz et al. similarly looked at MCA from 2010 to 2014 using data from the Toronto Regional RescuNet cardiac arrest database:
Category: Airway Management
Keywords: had, wrist, carpal (PubMed Search)
Hook of hamate fracture
Often missed fracture despite classic history
A frequent athletic injury
Seen in stick sports (golf, baseball, hockey)
Typically caused by a direct blow (grounding a gold club)
Patient presents with hypothenar pain and pain with tight gripping
Presentation may be subacute with longstanding wrist or palmer pain
Physical exam: Tender to palpation over hook of hamate
Specialized test: hook of hamate pull test
Supinated hand held in ulnar deviation. Ask patient to actively flex 4th and 5th digits against resistance at DIP.
Radiology: Consider adding carpal tunnel view to standard wrist series if diagnosis is suspected
CT sometimes needed to image the fracture
Tx: Immobilize in a short arm splint
Keywords: tramadol, seizure, risk factors (PubMed Search)
Therapeutic use or overdose of tramadol has been associated with seizure. However, it is unknown if there are any specific predisposing factor that increases a patient’s risk of seizure after tramadol use/overdose.
In a recently published study, eighty patient data with single ingestion of tramadol were reviewed.
Risk of seizure
In this small study, Asian patients and patients with abuse/misuse were at higher risk of developing seizure compared to patients who overdose tramadol.
Murray, BP et al. Seizures in tramadol overdoses reported in the ToxIC registry: predisposing factors and the role of naloxone. Clin Toxicol. 2018 DOI: 10.1080/15563650.2018.1547826
Keywords: stroke, thrombolytics, tPA (PubMed Search)
Powers WJ et al. 2018 Guidelines for the Early Management of Patients With Acute Ischemic Stroke A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke. 2018;49. DOI: 10.1161/STR.0000000000000158
Category: Critical Care
Respiratory Complications of ICIs
Ferreyro BL, Munshi L. Causes of acure respiratory failure in the immunocompromised host. Curr Opin Crit Care. 2019;25:21-8.
Keywords: anesthetic, orthopedics, wound (PubMed Search)
When caring for a patient with a laceration we often do lcoal infiltration prior to suturing but remember the benefits of regional nerve blocks
Benefits of Regional Nerve Blocks
Quick reminder of properities of common anesthetic
|Anesthetic||Onset of Action||Duration of Action|| Max Dose |
| Max Dose |
|Bupivicaine||Seconds +||> 6 hrs||2mg/kg||3mg/kg|
Final reminder: There is no evidence that epinephrine causes necrosis and it can be used safely in digital blocks. Duration of action is max 90 minutes. Even individuals that have injected themselves with EpiPens into their hands have not had any long term sequelue or necrosis seen. Vast majority required no treatment at all.
Keywords: Post-tonsillectomy, bleeding, airway (PubMed Search)
Post tonsillectomy hemorrhage occurs and 0.1-3% of post tonsillectomy patient's. It occurs typically greater than 24 hours after surgery and up to 4-10 days postoperatively. A survey of otolaryngologists showed that ED management strategies for active bleeding have included direct pressure, clot suction, silver nitrate, topical epinephrine, and thrombin powder.
This article was a case study demonstrating the use of nebulized tranexamic acid (TXA) for post tonsillectomy hemorrhage in a 3-year-old patient. The patient had a copious amount of oral bleeding and had failed treatment with nebulized racemic epinephrine and direct pressure was not an option due to the patient's cooperation and small mouth. 250 mg of IV TXA was given via nebulizer with a flow rate of 8 L. Bleeding stopped 5-7 minutes after completion of the nebulizer. The patient was then taken to the OR for definitive management. No adverse effects were noticed.
TXA in the pediatric population has been shown to decrease surgical blood loss and transfusions in cardiac, spine and craniofacial surgeries. Studies have also been done in pediatric patients with diffuse alveolar hemorrhage using doses of 250 mg for children less than 25 kg and 500 mg for those who are greater than 25 kg.
Bottom line: There are case reports of nebulized TXA use in the pediatric population with no adverse outcomes noted. More research is needed.
Schwarz W, Ruttan T, Bundick K. Nebulized Tranexamic Acid Use for Pediatric Secondary Post-Tonsillectomy Hemorrhage. Annals of Emergency Medicine 2018. Epub ahead of print.
Category: Critical Care
Keywords: Cardiac arrest, neruo (PubMed Search)
--Late awakening (>48h after sedation held) was common (78/402) in patients with cardiac arrest in prospective cohort study
--Poor prognostic signs of discontinuous (10-49% suppression) EEG and absent brain stem reflexes were independently associated with late awakening. Use of midazolam also associated with late awakening
--Late awakeners had good functional outcome when compared to early awakeners
DON'T NEUROPROGNOSTIC EARLY (OR IN ED)!
And traditional poor prognostic signs may not be as poor as previously thought!
Keywords: Skiing, gamekeeper (PubMed Search)
Epidemiology of Alpine Skiing Injuries
Mean age of injury 30.3 (range 24 to 35.4 years)
Populations at greatest risk are children and adolescents and possibly adults over 50 (increased risk of tibial plateau fractures)
Sex: Males> females
Knee injuries, esp to ACL, are higher among females
Fractures greater in males
Injury location greatest at lower extremity (primarily to knee)
Primarily sprains to MCL and ACL (increasing incidence)
14% occur to upper extremity and primarily involve the thumb and shoulder
Skiers thumb – FOOSH with thumb Abducted gripping pole
Pole is implicated as this injury is rare among snowboarders
The pole acts as a lever to amplify the forced Abduction of the thumb as the outstretched hand hits the ground.
Let go before you hit the ground!!
13% occur to head and neck
The number of all type injuries has decreased over time with advances in equipment and helmet use
Proportion of skiers wearing a helmet exceeds 80%
However, the number of traumatic fatalities has remained constant
Accidents involving fatalities exceed the protective capacity of helmets
Helmets likely decrease risk of mild and moderate head injury
Ekeland et al., 2018. Epidemiology of Alpine Skiing Injuries. J Sci Med Sport
Davey et al., 2018. Alpine Skiing Injuries. Sports Health
Keywords: ADEM (PubMed Search)
Acute Disseminated Encephalomyelitis (ADEM) is primarily a pediatric disease and can cause a wide variety of neurologic symptoms. As such, should always be in the differential for pediatric patient presenting with vague neurologic symptoms including altered mental status. It is an immune-mediated, demyelinating disease that can affect any part of the CNS; usually preceding a viral illness or rarely, immunizations.
The average age of onset is 5-8 years of age with no gender predilection. It usually has a prodromal. That includes headache, fever, malaise, back pain etc. Neurological symptoms can vary and may present with ataxia, altered mental status, seizures, focal symptoms, behavioral changes or coma.
MRI is the primary modality to diagnose this condition. Other possible indicators may be mild pleocytosis with lymphocyte predominance, and elevated inflammatory markers such as ESR, CRP. These findings, however, are neither sensitive nor specific.
First-line treatment for ADEM is systemic corticosteroids, typically 20-30 mg/kg of methylprednisolone for 2-5 days, followed by oral prednisone 1-2 mg/kg for 1-2 weeks then 3-6-week taper. For steroid refractory cases, IVIG and plasmapheresis may be considered.
ADEM usually has a favorable long-term prognosis in the majority of patients. However, some may experience residual neurological deficits including ataxia, blindness, clumsiness, etc.
Take home points:
Gray, M.P. & Goralick, M.H. (2016). Acute disseminated encephalomyelitis (6th ed, volume 32). Milkwaukee, WI
Keywords: take home naloxone, opioid overdose (PubMed Search)
Take home naloxone (THN) programs have been expanded to help reduce the opioid overdose-related deaths. A study was done in Australia to characterize a cohort of heroin overdose deaths to examine if there was an opportunity for a bystander to intervene at the time of fatal overdose.
235 heroin-overdose deaths were investigated during a 2 year study period in Victoria, Australia.
Stam NC et al. Challenges with take-home naloxone in reducing heroin mortality: a review of fatal heroin overdose cases in Victoria, Australia. Clin Toxicol 2018 Nov 17:1-6. doi: 10.1080/15563650.2018.1529319. [Epub ahead of print]