The role of skeletal muscle relaxants in the management of lower back pain in the ED

Patients with lower back pain (LBP) presenting to the ED are often treated with NSAIDs plus skeletal muscle relaxants.

A recent study in Annals of Emergency Medicine compared functional outcomes and pain in ED patients with acute non radicular LBP with 4 different treatment regimens.

1. Ibuprofen plus placebo
2. Ibuprofen plus baclofen
3. Ibuprofen plus metaxalone
4. Ibuprofen plus tizanidine

Conclusion: Adding a muscle relaxant to ibuprofen did not improve pain or improve function at 1 week following an ED visit for LBP.

Note: Prior studies have found no benefit to adding opioids or diazepam to NSAIDs  for ED patients with acute non radicular LBP

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As of November 20, 2019:

2290 cases of e-cigarette, or vaping, product use-associated lung injury (EVALI) from 49 states (except Alaska), District of Columbia and 2 U.S. territories.

• Largest number of cases (150-199) reported from CA, TX and IL
• 47 deaths

Analysis of 29 bronchoalveolar lavage (BAL) fluid samples from EVALI patients submitted to CDC from 10 states showed:

• Vitamin E acetate in all samples 
• THC: 82%
• Nicotine: 62%
• No other chemicals of concern were identified (e.g. plant oil, mineral oil, terpenes, etc.) 

*** Vitamin E acetate appears to be associated with EVALI but the investigation is continuing.*** 

• Oral ingestion of vitamin E acetate does not cause harm.
• High dose vitamin E supplementation (>2000 IU/day [2000 mg/day]) can cause GI symptoms: nausea, vomiting, diarrhea and abdominal pain.

Some research has suggested that oral vitamin E use has potential beneficial effects (i.e. anti-inflammatory/antioxidant) in the lung (e.g. asthma and allergic lung disease), cardiovascular disease and prostate cancer (Cook-Mills JM et al. 2013; Jiang Q et al. 2001)

Common uses of vitamin E

• Topical cosmetic skin products (skin cream) for antioxidant effect.
• Essential dietary vitamin (fat soluble) found in many food items and as dietary supplement.
• In vaping products: vitamin E is used as an additive/thickening agent in THC containing e-cigarette, or vaping products.

There is limited to no data on pulmonary effect of vitamin E from inhalation in the scientific literature.

Stay tuned for additional updates from CDC.

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1. Decreased hepatic function
2. Decreased renal function
3. Multiple comorbidities and polypharmacy that can affect pharmokinetics of pain medications.

Therefore, pain medications must be dosed carefully, which runs the risk of underdosing.  Pain medications can also contribute to delerium, and decreased functional status.

Recommendations:

1. Start with non-opioid medications in most cases. Consider combination acetaminophen and ibuprofen/naproxen.
2. Consider regional nerve blocks where applicable due to the decreased risk of systemic side effects and excellent analgesic properties.
3. If using opioids, start low and reassess and use the lowest dose possible. Remember half-lifes are often prolonged so patient may not need the standard dosing interview.

Streptococcal pharyngitis is common in the pediatric population however in children younger than 3 years, group A streptococcus (GAS) is a rare cause of sore throat and sequela including acute rheumatic fever are very rare.  Inappropriate testing leads to increased healthcare and unnecessary exposure to antibiotics.

The national guidelines published by the Infectious Diseases Society of America do NOT recommend GAS testing in children less than the age of 3 years unless the patient meets clinical criteria and has a home contact with documented GAS.

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Metformin is one of the most commonly prescribed oral hypoglycemic agents. Metformin associated lactic acidosis (MALA) is uncommon but potentially life-threatening complication of metformin overdose. 

Lactic acidosis occurs due to inhibition of mitochondrial glycerophosphate dehydrogenase, resulting in decreased conversion of lactic acid to pyruvate.

A small retrospective study (using Illinois Poison Center data) attempted to characterize the development of MALA after an acute overdose.

MALA was defined as 

• Lactate: > 5 mmol/L
• Acidemia: (HCO₃< 20 mmol/L or pH < 7.35)

Results

40 cases of MALA identified between Jan. 2001 to Dec. 2014

• Meadian age: 41 year
• Female: 55%
• Acute on chronic ingestion: 62.5%
• Hypoglycemia: 3 (7.5%)

Time to development of MALA (n=30)

• <=6 hours: 18 (60%)
• 6-12 hours: 9 (30%)
• >12 hours: 3 (10%)
• Unknown: 10

Death: 1 (2.5%)

Conclusion

1. The majority of MALA developed within 6 hours. However, delayed onset of MALA can occur, up to 12 hours post ingestion.
2. Minimum of 12 hour of observation is recommended after an acute metformin overdose.

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When managing cardiac arrest, it is important to differentiate PEA, the presence of organized electrical activity without a pulse, from "pseudo-PEA,"where there is no pulse but there IS cardiac activity visualized on ultrasound. 

Why: 

• Pseudo-PEA is essentially a profound, low-flow shock state that often has reversible causes, such as hypovolemia, massive PE, tension pneumothorax, etcetera.
• Compared to PEA, with appropriate care patients with pseudo-PEA have a higher rate of ROSC as well as overall survival.

How: 

• POCUS during rhythm check in cardiac arrest. Be careful not to prolong the pause in compressions; acquire the US, if needed, for review once hands are back on the chest. 

What:

• In addition to searching for & addressing reversible causes of the pseudo-PEA, manage the profound shock state with pressors and/or inotropic support.
• In EDs where TEE is utilized during cardiac arrest resuscitations, strongly consider synchronization of external compressions with intrinsic cardiac activity to potentially improve ventricular filling and therefore coronary perfusion pressure.

Bottom Line: Pseudo-PEA is different from PEA. Utilize POCUS during your cardiac arrests to identify it and to help diagnose reversible causes, and treat it as a profound shock state with the appropriate supportive measures, i.e. pressors or inotropy. 

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Lateral hip pain is a common presentation of hip pain.

Typically seen in runners and women over the age of 40 who start unaccustomed exercise.

Pain from OA of the hip which is typically medial (groin pain)

Lateral hip pain has traditionally been diagnosed at trochanteric bursitis.

Research suggests that lateral hip pain may be multifactorial and better termed Greater trochanteric pain syndrome.

Pain from the gluteal medius and/or minimus due to non-inflammatory tendonopathy is likely causative. This may cause a secondary bursitis.

Pain is insidious, gradual worsens and is variable based on activity type.

Also, can be seen after a fall resulting in tearing.

Pain is described as a deep ache or bruise. It can stay localized or radiate down lateral thigh towards knee.

Patients report night/early morning pain and when rolling over onto the outer hip on affected side.

Fatigue from prolonged sitting, walking and single leg loading activities such as walking up stairs.

Provoking activities and postures cause compressive forces on the involved tendons.

            These generally occur when the hip is adducted across midline such as with

Side sleeping,

            Place pillow between legs to align pelvis and keep knee and hip in line

Crossed leg sitting

            Sit w/ knees at hip distance and feet on floor

Selfie poses - Standing w a hitched hip (pushing hip to the side).

Attempt to correct biomechanical issues before progressing directly to bursal steroid injection

            May only be a temporary fix if underlying issue not addressed.

A helpful clinical guide

https://bjgp.org/content/bjgp/67/663/479/F1.large.jpg?download=true

Droperidol has recently become available again in select U.S. institutions. It has been used as an antiemetic and to treat agitation prior to the FDA’s black box warning (for QT prolongation) and national shortage. 

Recently, a retrospective study was conducted (Melbourne, Australia) in the use of droperidol in the management of cannabinoid hyperemesis syndrome (CHS).

Results

689 medical records were identified from January 2006 to December 2016.

76 cases met diagnostic criteria of CHS (below)

• Long-term cannabis use
• Symptoms of recurrent vomiting
• Absence of illness that could otherwise explain symptoms.

Droperidol group (DG) = 37; no droperidol group (NDG)= 39 

Median length of stay: 

• DG: 6.7 hr vs. NDG: 13.9 hours (p=0.014)

Median time to discharge after final drug administration: 

• DG: 137 min (IQR: 65, 203) vs. NDG: 185 min (IQR: 149, 403)

Frequency of droperidol (dose) used: 

1. 0.625 mg (n=25)
2. 1.25 mg (n=20)
3. 2.5 mg (n=17)

Metoclopramide and Ondansetron use in non-droperidol group was twice that of droperidol group

Conclusion

• Droperidol use to treat CHS associated nausea/vomiting resulted in decreased length of stay and lower use of antiemetics.  

Phenytoin can be a complex medication.  There are different levels than can be ordered, adjustments based on albumin, various pharmacokinetic equations, and multiple formulations.  Below are the simplified answers to some of the most common questions (see in-depth section for explanations):

Which phenytoin level (free or total) do I order?

Total Phenytoin Level.

What do I do after the level results?

Undetectable Level: Load patient with 20 mg/kg of total body weight (max dose 1,500 mg).

Subtherapeutic Level (<10 mcg/mL): Calculate an approximate loading dose using this equation….Phenytoin Dose (mg)=(15-measured total level)*(0.7*patient weight).

Therapeutic Level (10-20 mcg/mL): Add an additional agent.

Supratherapetutic/Toxic Level (>20 mcg/mL): Contact Poison Center (1-800-222-1222).

What formulation do I order for loading?

IV: Use fosphenytoin.

PO: Any formulation will work.  Give as a single loading dose or, if concerned for GI upset, give in 2-3 divided doses separated by 2 hours.

***Disclaimer: These answers are simplified for the initial management of most patients in the ED. More complex answers may be required in some situations.***

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Ever been in an acute rescucitation and found yourself unable to remember all of those famous ACLS Hs and Ts?  I know I have.  A few years ago Littman et al published an alternative approach to critically ill, hypotensive medical patients with non shockable rhythms.  Unfortunately, it seems like some of the enthusiasm for this approach has died down, but I still think it's something you're more likely to recall in a pinch than the Hs and Ts and is a better way of getting started with a hypotensive non-trauma patient.  And it's so simple you may actually remember it!

1) Look at the monitor.  Is the rhythm narrow or wide?  

2a) Narrow - more likely a mechanical problem (tamponade, tension PTX, autoPEEP, or PE). Give IVF and search for one of these causes (and correct it!).  Keep in mind that ultrasound can help you differentiate a lot of these.

2b) Wide - more likely a metabolic problem (hyperK, sodium channel blockade, etc*). Give empiric calcium, bicarb, and other therapies targeted for these problems (if desired) and get stat labs.

Take a minute and either go to this REBEL EM post:

https://rebelem.com/a-new-pulseless-electrical-activity-algorithm/

To review this, or look at the attached diagrams.  

*Dr. Mattu would want me to remind you that hyperkalemia IS a sodium channel poisoned state, so there's no need to think of these two separately

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Attachments

• 1910292200_Narrow-Complex-PEA-Management-765x456.jpg (96 Kb)
• 1910292201_Wide-Complex-PEA-Management-765x444.jpg (83 Kb)

A recent epidemiology study in Pediatrics looked at concussions in 20 high school sports during the 2013–2014 to 2017–2018 school years.

For every athlete, one practice or competition was counted as one exposure.

Overall, 9542 concussions were reported for an overall rate of 4.17 per 10 000 athletic exposures (AEs).

Football continues to have the highest incidence with a concussion rate of 10.40 per 10 000 AEs.

As in previous studies, rates in competition (33.19 to 39.07 per 10 000 AEs) are increasing and higher than rates in practice which are lower and decreasing over the study period (5.47 to 4.44 per 10 000 AEs).

            This may reflect better reporting or increasing injury rate

In all 20 sports, recurrent concussion rates decreased from 0.47 to 0.28 per 10 000 AEs.

Confirming prior studies, among sex-comparable sports, concussion rates were higher in girls than in boys (3.35 vs 1.51 per 10 000 AEs).

Also, among sex-comparable sports, girls had larger proportions of concussions that were recurrent than boys (9.3% vs 6.4%).

This study may reflect effective implementation of strategies to reduce concussion incidence such as mandatory removal from play and more stringent requirements associated with return to play.

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• Resuscitation with crystalloid fluid is a cornerstone of pediatric septic shock treatment.
• Recent publication from the adult literature have suggested that balance crystalloid solutions may be better than 0.9% normal saline (NS) for select conditions.
• Lactated Ringer's (LR) is a common balance crystalloid solution often used for fluid resuscitation and critically ill patients.
• However whether resuscitation with balance fluids is associated with improved outcomes compared to NS in pediatric sepsis is unclear.
• A matched retrospective cohort study of 12,529 pediatric patient with severe sepsis/septic shock at 382 US hospitals compared outcomes with versus without LR as a part of the initial resuscitation.
• Outcomes includesd: 30-day hospital mortality, acute kidney injury, new dialysis, and length of stay.
• After matching, mortality was not different between LR and NS groups. There were no differences in secondary outcomes except longer hospital length of stay in the LR groups.
• The PRoMPT BOLUS randomized control trial pilot was a feasibility study designed to study the comparative effectiveness of LR versus NS fluid resuscitation for pediatic septic shock.  Completion of a more robust study may help provide answers to these ongoing questions. 

Bottom line: Balance fluid resuscitation with LR was not associated with improved outcomes compared to NS and pediatric sepsis. Selective LR use necessitates a prospective trial to definitively determine comparative effects among crystalloids.

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Patients with drug-induced cardiogenic shock [DIC] (e.g. overdose of CCB/BB, membrane stabilizing agents, etc.) are often managed with medical interventions such as vasopressors, bicarbonate infusion, high-dose insulin, lipid emulsion therapy. A fraction of these patients may be refractory to the standard medical therapy. VA-ECMO (venoarterial extracorporeal membrane oxygenation) has been utilized in such situation; yet clinical experience of using VA-ECMO in DIC is limited.

A recent retrospective study of the Extracorporeal Life Support Organization’s ECMO registry showed

• Increasing VA-ECMO utilization for drug-induced cardiogenic shock (n=104) over the past 15 years (2003 to 2018) but it represents a fraction (0.067%) of VA-ECMO use.
• VA-ECMO improved hemodynamic and metabolic status at 24 hrs-post cannulation.
• Persistent acidosis (HCO3 level) and acidemia (pH) at 24 hrs-post cannulation was associated with mortality.
• 52.9% of the cases survived to discharge. 

Conclusion

• VA-ECMO may be clinically beneficial (improvement of hemodynamic and metaboic status) in patients with refractory drug-induce cardiogenic shock

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• Cryptococcal meningitis is the most common fungal CNS infection that predominantly affects immunocompromised patients.
• However, cases have been described in immunocompetent patients.
• Clinical presentation may include headache, fever, neck pain, nausea, vomiting, light sensitivity, seizure, or altered mental status.
• Neuroimaging is usually normal, though cryptococcomas, pseudocysts, and obstructing hydrocephalus can be seen.
• Diagnosis with LP include elevated opening pressure, mononuclear predominance of cell count, low glucose, high protein, India ink microscopy, Cryptococcal antigen testing, and CSF culture.
• Subacute symptoms contribute to delay in diagnosis which increases overall morbidity and mortality.

Bottom Line: Consider cryptococcal meningitis even in immunocompetent patients.

ICU admission rates for all acute PEs vary wildly across the country (<5% to ~80%).

To predict which hemodynamically stable, normotensive PE patients should be admitted to the ICU, a single-center retrospective analysis of 7 years’ data sought to describe the reasons why normotensive patients with PE required vasopressors within 48 hours of admission to the ICU. The authors studied 293 patients admitted to the ICU at Beth Israel Deaconess in Boston and found only 8 patients (2.7%) who decompensated within the first 2 days.  Of MANY variables studied, only respiratory rate was significantly different between those who decompensated and those who did not (mean RR 29 with range 26-32 in the decompensated group vs mean 21 with range 17-24).

Bottom Line: cost control experts may lean on you to admit fewer PE patients to the ICU. There is no perfectly reliable way to predict which normotensive patient with a PE will decompensate. The PESI score has been validated but even the low risk cohort had 1.6% mortality at 3 days. The BOVA score has been validated but its endpoint of mortality at 30 days is less useful for planning admission. Tachypnea should concern you.

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The Critically Ill Geriatric Patient with Sepsis

• Due to the age-related physiologic change of immunosenescence, geriatric patients have an increased susceptibility to infection, a decreased ability to mount a response to infection, and an increased likelihood of atypical presentations.
• Atypical presentations of sepsis in the geriatric patient include confusion, decreased functional status, generalized weakness, and failure to thrive.
• In fact, up to 33% of geriatric patients with bacteremia will be afebrile upon presentation.
• Consider sepsis in the differential diagnosis of geriatric patients with these nonspecific complaints.

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Synthetic turf playing surfaces have been growing in popularity over the last decade and seem to have become a new standard.

Due to the need for durable fields that can accommodate multiple teams/activities, in addition to the high cost of maintaining grass and the need to conserve water, many parks and schools have switched from grass to turf. Turf is advertised as maintenance free but ….this is not the case.

Locally, at M&T Bank Stadium, groundskeepers drive a LitterKat turf sweeper across the field for 4 hours 2-3 times a week to ensure that the synthetic rubber is cleaned and distributed evenly. The field is also repainted every 4 games because the paint may become hard. The cost of this level of maintenance is beyond what many parks and local high schools can afford.

A recent study examined high school concussion data at almost 2000 high schools with over 14,000 recorded concussions. Researchers concluded that more concussions occurred in games than practices. Interestingly, they also found that playing surface was significantly associated with concussion. Almost 90% of all injuries occurred on turf-based surfaces. Turf outweighed all other mechanisms of injury, including helmet-to-helmet hits and grass playing surface. Between 10 and 15.5% of concussions occur from helmet to ground contact. In the NFL, this mechanism accounts for about 1 in 7 concussions.

Attempting to limit total exposure time in practice and games on turf surfaces may be beneficial until more study is needed.

The rate of suicide attempt has been increasing over the past decade. A recently published article investigated the temporal trend of suicide attempts in adolescent/young adult population (10 – 25 years old) from 2000 to 2018.

 Methods

• All intentional – suspected suicide cases were identified from the National Poison Data System from Jan 1, 2000 to December 31, 2018. 
• Following age groups were compared: 10-12, 13-15, 16-18, 19-21 and 22-25 years old.

Results

• A total of 1,677,435 cases were identified with 0.1% fatality (n=1579).
• Female: 70.6% (n=1,184,691) 
• Single substance (64.1%; n=1,074,423)
• Highest suicide attempt rate: 16-18 years (30.1%; n=504,682)
• Lowest suicide attempt rate: 10-12 years (2.3%; n=38,428)

• The suicide attempt rate increased significantly starting 2011 in 10-12, 13-15 and 16-19 years age groups with seasonal trend
  •  Higher during school months (Sept to May) vs. non-school months (June-August)

Top 5 substance involved in suicide attempt

1. OTC analgesics
2. Antidepressants
3. Sedative hypnotics
4. Antihistamines
5. Antipsychotics

Agents associated with serious medical outcome (after 2011)

1. Antidepressants
2. OTC analgesics
3. Antihistamines 
4. ADHD medications

• ADHD medicaitons: common in 10-15 years population
• Sedative hypnotics (e.g. benzodiazepines): common in older age group (16-25 years)

Conclusion

• Rate of suicide attempt in adolescent and young adults has increase, especially since 2011.
• The substance used in suicide attempt usually involves medications available to the specific age group.
• OTC medications (analgesics and antihistamines) were involved in a third of the suicide attemps.

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Rationale: Data regarding temperature management in patients suffered from cardiac arrest with nonshockable rhythm was inconclusive.

Objective: whether moderate hypothermia at 33C, compared with normothermia at 37C would improve neurologic outcome in patients with coma after cardiac arrest with nonshockable rhythm.

Outcome: survival with favorable 90-day neurologic outcome (Cerebral Performance Category scale 1-2/5)

SummaryThere was higher percentage of patients achieving CPC 1-2 in the hypothermia group (10.2%) vs normothermia group (5.7%, Hazard Ratio 4.5, 95% CI 0.1-8.9, p=0.04)

This randomized multicenter trial involved 581 patients with cardiac arrest and nonshockable rhythm.  Hypothermia group included 284 patients vs. 297 in the normothermia group.  Median GCS at enrollment = 3.

Majority of patients was cooled with the use of a basic external cooling device: 37% for hypothermia and 50.8% for normothermia group.

There was higher percentage of patients achieving CPC 1-2 in the hypothermia group (10.2%) vs normothermia group (5.7%, Hazard Ratio 4.5, 95% CI 0.1-8.9, p=0.04)

Limitation:

A. The study used strict enrollment criteria:

1. CPR initiation within 10 minutes;
2. CPR to ROSC within 60 minutes;
3. epinephrine or norepinephrine infusion at < 1 ug/kg/min;
4. No Child-Pugh class C liver cirrhosis

B. normothermia group had higher proportion of patients with temperature at 38C.

C. Hypothermia group underwent temperature management of 56 hours vs. 48 hours for normothermia patients.

Take home points:

In a selected group of patients with cardiac arrest and nonshockable rhythm, moderate hypothermia at 33C may improve neurologic outcome.

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