Category: Critical Care
Study Question: What is the association of relative hypotension (degree and duration of MPP deficit) in patients with vasopressor-dependent shock with the incidence of new significant AKI and major adverse kidney events (MAKE)?
Panwar R, Tarvade S, Lanyon N, et al. Relative hypotension and adverse kidney-related outcomes among critically ill patients with shock. A multicenter, prospective cohort study. Am J Respir Crit Care Med. 2020;202(10):1407-1418.
Category: Pharmacology & Therapeutics
Keywords: Octreotide, Vasopressin, Variceal Bleeding (PubMed Search)
With a national shortage of octreotide an alternative treatment plan had to be implemented at our institution for patients presenting with variceal bleeding.
Drug references recommend a continuous infusion of vasopressin at 0.2 to 0.4 units/minute. Dose may be titrated as needed to a maximum dose of 0.8 units/minute with maximum duration of 24 hours to reduce incidence of adverse effects. Administer IV nitroglycerin concurrently to prevent ischemic complications and monitor closely for signs/symptoms of myocardial, peripheral, and bowel ischemia.
Protocol at our institution:
Initiate vasopressin at 0.2 units/min.
Increase by 0.2 units/min if bleeding is not controlled after one hour (max dose: 0.8 units/min).
If bleeding controlled for 2 hours, can decrease by 0.2 units/min and reassess.
Limit use to 24 hours.
Use nitroglycerin infusion to prevent adverse effects from vasopressin.
Initiate nitroglycerin at 40 mcg/min, titrate by 40 mcg/min to a max dose of 400 mcg/min.
Goal systolic blood press pressure of 90-100 mmHg. Do not start nitroglycerin if SBP <90 mmHg.
***Please note the vasopressin dose for this indication is significantly higher than the typical dose of 0.03 units/min we use for shock.***
Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American Association for the Study of Liver Diseases [published correction appears in Hepatology. 2017;66(1):304]. Hepatology. 2017;65(1):310-335.
Terés J, Planas R, Panes J, Salmeron JM, Mas A, Bosch J, Llorente C, Viver J, Feu F, Rodés J. Vasopressin/nitroglycerin infusion vs. esophageal tamponade in the treatment of acute variceal bleeding: a randomized controlled trial. Hepatology. 1990 Jun;11(6):964-8.
Vasopressin. Lexicomp. UpToDate. Waltham, MA: UpToDate Inc. Available at: https://www.uptodate.com. Accessed on December 31, 2020.
Keywords: Serum insulin level table (Attachment) (PubMed Search)
Keywords: high dose insulin. insulin kinetic (PubMed Search)
High dose insulin (HDI) therapy is commonly used in patients with severe beta-adrenergic antagonist and calcium channel antagonist overdose. Hypoglycemia and hypokalemia are commonly known complication of HDI therapy. However, kinetics of insulin in patients who received HDI therapy is unknown.
A 51 year-old man with amlodipine overdose was infused HDI (10 unit/kg/hr) for 37 hours; Serial serum insulin levels were drawn after discontinuation of HDI.
Serum insulin levels are shown in below table
The serum insulin level remained significantly elevated during the first 24 hours (normal range: 2.6-24.9 microU/mL) and gradually decreased over 6 days.
Corcoran JN et al. Persistent hyperinsulinemia following high-dose insulin therapy: a case report. J Med Toxicol 2020;16:465-469.
Keywords: Hip pain, snapping hip, tendon (PubMed Search)
Chief complaint: “My hip snaps when I exercise”
Both athletes and non-athletes may report a “snapping” sound with certain movements
This may affect up to 10% of the population
May be associated with activities than involve repetitive hip flexion
Symptoms may be due to an internal or an external cause
External causes are usually due to a tendon passing over a bony prominence
This can be felt as either an audible sensation and/or even a palpable snap
This may or may not involve pain or discomfort
This is most commonly due to a benign cause
During movements in flexion, extension or combined with internal rotation the iliotibial band may move over the greater trochanter.
Alternatively, the hamstring tendon may pass over the ischial tuberosity
There are several other causes with similar mechanisms
Symptoms are usually minimal and not serious
This can be reproduced on bedside clinical exam
Ask the patient to identify the area of snapping with one finger which will help with anatomic localization
First line therapy is physical therapy which focuses on:
Improving muscle length if muscle is too tight OR
Improving neuromuscular activation if problem is due to excessive muscle activation
Keywords: Procalcitonin, febrile infants, sepsis (PubMed Search)
Young infants (0-90 days) have immature immune systems and are at higher risk for serious bacterial infections, particularly urinary tract infections, bacterial meningitis, and bacteremia. Infants less than 90 days old have an incidence of bacterial infections between 8 to 12.5%, while infants less than or equal to 28 days old have almost a 20% incidence.
Risk-stratification of this group has been a huge focus of research over the past couple of decades to help identify which patients require a full sepsis work-up, particularly in well-appearing infants if a source of fever is identified early. Recent studies have explored the utility of biomarkers in risk stratification in this population. A better ability to discriminate would hopefully decrease unnecessary lumbar punctures, antibiotic use, and hospital admission. Multiple studies have shown procalcitonin is able to outperform CRP for prediction of serious bacterial infections. Kuppermann et al developed a tool to identify low risk febrile infants < 60 days using procalcitonin and ANC. Their prediction rule gave a 97.7% sensitivity, 60% specificity, and 99.6% NPV for serious bacterial infection. There have been several other studies that have looked harder to detect infections such as osteomyelitis or septic arthritis across all pediatric patients and the data has not been as promising.
Bottom line: Procalcitonin shows promise as part of a risk stratification tool in infants younger than 60 days. Other studies have failed to show its relevance as a screening tool for osteomyelitis, septic arthritis, renal abscess or community acquired pneumonia.
Huppler AR, Eickhoff JC, Wald ER. Performance of low-risk criteria in the evaluation of young infants with fever: review of the literature. Pediatrics. 2010;125(2):228-233. doi:10.1542/peds.2009-1070
Schwartz S, Raveh D, Toker O, Segal G, Godovitch N, Schlesinger Y. A week-by-week analysis of the low-risk criteria for serious bacterial infection in febrile neonates. Archives of Disease in Childhood. 2009;94(4):287-292. doi:10.1136/adc.2008.138768
Woll C, Neuman MI, Aronson PL. Management of the Febrile Young Infant: Update for the 21st Century. Pediatr Emerg Care. 2017;33(11):748-753. doi:10.1097/PEC.
Kuppermann N, Dayan PS, Levine DA, et al. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatr. 2019;173(4):342-351. doi:10.1001/jamapediatrics.
Keywords: Balance, mBESS, concussion (PubMed Search)
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).
B) Single leg stance
C) Tandem Stance
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
Keywords: physostigmine, lorazepam, anticholinergic toxicity, delirium (PubMed Search)
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.
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
Study duration: March 20, 2017 to June 30, 2020
Antimuscarinic agent ingested
Proportion of subject with delirium by CAM-ICU
Prior to first bolus (p >0.99)
After 1st bolus (p=0.01)
End of 4 hr infusion (p <0.001)
No adverse events noted in both group
Wang GS et al. A randomized trial comparing physostigmine vs lorazepam for treatment of antimuscarinic (anticholinergic) toxidrome. Clin Toxicol (Phila.) 2020. Dec 9. Online ahead of print. https://doi.org/10.1080/15563650.2020.1854281
Keywords: acute ischemic stroke, guideline, metric, English, non-English (PubMed Search)
Bottom Line: Patients' language preference does not appear to affect the efficiency of acute ischemic stroke care, especially at experienced high volume stroke centers.
Zachrison KS, Natsui S, Luan Erfe BM, et al. Language preference does not influence stroke patients' symptom recognition or emergency care time metrics. Am J Emerg Med. 2020 Nov 2 [Online ahead of print]
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Category: Critical Care
PEEP in the Intubated Obese Patient
De Jong A, et al. How to ventilate obese patients in the ICU. Intensive Care Med. 2020; 46:2423-35.
Category: Pharmacology & Therapeutics
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.
Heffner, A. C., Swords, D. S., Neale, M. N. & Jones, A. E. Incidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation 84, 1500–1504 (2013).
Hill, K. Cardiac Arrests Associated with Tracheal Intubations in PICUs: A Multicenter Cohort Study. The Journal of Emergency Medicine 51, 617–618 (2016).
Kim, W. Y. et al. Factors Associated with the Occurrence of Cardiac Arrest after Emergency Tracheal Intubation in the Emergency Department. PLoS ONE 9, e112779 (2014).
Pokrajac, N. et al. Risk Factors for Peri-intubation Cardiac Arrest in a Pediatric Emergency Department Pediatric Emergency Care Publish Ahead of Print, (2020).
Keywords: ethanol exposure, infant, national poison data system. (PubMed Search)
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.
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.
Clinically significant effects
563 infants (31%) were evaluated at hospital
38% (n=214) of the exposures were hospitalized
0-5 months of age
Ethanol exposure among infants is increasing each year and associated with serious clinical effects.
Gaw CE et al. Beverage ethanol exposure among infants reported to United States pison control centers 2020 Clin Toxicol (Phila) https://doi.org/10.1080/15563650.2020.1843658
Keywords: Shoulder, biceps, tendon (PubMed Search)
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?
Pathology is often the long head of the biceps
Start by palpating this area and attempt to reproduce the discomfort
Keywords: vaginitis, vaginal discharge (PubMed Search)
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.
McCaskill A, Inabinet CF, Tomlin K, Burgis J. Prepubertal Genital Bleeding: Examination and Differential Diagnosis in Pediatric Female Patients. J Emerg Med. 2018 Oct;55(4):e97-e100. doi: 10.1016/j.jemermed.2018.07.
Loveless M, Myint O. Vulvovaginitis- presentation of more common problems in pediatric and adolescent gynecology. Best Pract Res Clin Obstet Gynaecol. 2018 Apr;48:14-27. doi: 10.1016/j.bpobgyn.2017.08.014. Epub 2017 Sep 5. PMID: 28927766.
Manning S. Genital Complaints at the Extremes of Age. Emerg Med Clin North Am. 2019 May;37(2):193-205. doi: 10.1016/j.emc.2019.01.003. PMID: 30940366.
Category: Critical Care
Keywords: vasopressor, peripheral IV, safety (PubMed Search)
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.
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.
Complication of vasopressor infusion through peripheral venous catheter: A systematic review and meta-analysis
Quincy K Tran, Gaurika Mester, Vera Bzhilyanskaya, Leenah Z Afridi, Sanketh Andhavarapu, Zain Alam, Austin Widjaja, Brooke Andersen, Ann Matta, Ali Pourmand.
Am J Emerg Med. 2020 Sep 28;S0735-6757(20)30842-1. doi: 10.1016/j.ajem.2020.09.047. Online ahead of print.
Category: Critical Care
Keywords: Hyponatremia (PubMed Search)
Baek SH, Jo YH, Ahn S, et al. Risk of overcorrection in rapid intermittent bolus vs slow continuous infusion therapies of hypertonic saline for patients with symptomatic hyponatremia: the salsa randomized clinical trial. JAMA Intern Med. Published online October 26, 2020.
Keywords: migraine, headache, diagnosis, treatment, prevention (PubMed Search)
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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Category: Pharmacology & Therapeutics
Keywords: Beta-Lactam, Allergies, Sepsis (PubMed Search)
Komyathy KL, Judd WR, Ratliff PD, Hughes RE. Assessing mortality outcomes of beta-lactam-allergic patients presenting with sepsis. Am J Emerg Med. 2020;38(9): 1816-1819.
Keywords: pain management, ketamine (PubMed Search)
Silva LOJ, Lee JY, Bellolio F, Homme JL, Anderson JL. Intranasal ketamine for acute pain management in children: A systematic review and meta-analysis. American Journal of Emergency Medicine. 2020 (38)1860-1866. doi: 10.1016/j.ajem.2020.05.094