UMEM Educational Pearls

• The Glasgow Coma Scale (GCS) is an instrument widely used to assess level of consciousness by EMS.
• The motor GCS (mGCS) and Simplified Motor Scale (SMS) have been proposed to simplify EMS triage.
• A number of retrospective studies have compared these scales.
• Chou et al. performed a systematic review and meta-analysis of 18 studies with a total number of 1.7 million patients to compare the predictive utility of these scales for identification of patients with severe traumatic injury.
• The total GCS was slightly better than the mGCS or SMS on predicting mortality, neurosurgical intervention, severe traumatic brain injury, and emergent intubation.

Bottom Line:  The motor GCS and Simplified Motor Scale (SMS) have similar discrimination when compared with the total GCS, and may be easier to use.

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The deleterious effects of hyperoxia are becoming more and more apparent. But obtaining a blood gas to ensure normoxia in a busy Emergency Department can be burdensome. And while the utilization of a non-invasive pulse oximeter seems ideal, the threshold that best limits the rate of hyperoxia is unclear.

Durlinger et al in a prospective observational study demonstrated that an oxygen saturation 95% or less effectively limited the number of patients with hyperoxia (PaO2 of greater than 100 mm Hg). Conversely when an SpO2 of 100% was maintained, 84% of the patients demonstrated a PaO2 of greater than 100 mm Hg.

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Most of our knowledge of the athlete’s EKG is based on white athletes.

African/Afro-Caribbean athletes are more likely to have an abnormal EKG than white athletes in multiple studies.

Different selective criteria have been developed to minimize classification of benign normal patterns as abnormal.

The 2010 ESC criteria classified 40.4% of black athletes as abnormal versus the Refined criteria which resulted in 11.5% of EKGs classified as abnormal.

This reduction was aided by the recognition that isolated anterior TWI in asymptomatic black athletes is considered a benign finding.

               Note this does NOT apply if the TWI extend to the lateral leads

For example, T-wave inversion (TWI) was present in 23% of African/Afro-Caribbean athletes vs. 3.7% of white athletes (usually in contiguous anterior leads).

Other changes included a higher prevalence of early repolarization, RV hypertrophy, and LA/RA enlargement.

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FDA announced a shortage of sodium bicarbonate on 3/01/17.  Sodium bicarbonate is frequently used in acid-base disorder as well as in poisoning (cardiac toxicity from Na-channel blockade, e.g. TCA & bupropion, and salicylate poisoning).

Acetate is a conjugate base of acetic acid where acetate anion forms acetyl CoA and enters Kreb cycle after IV administration. Final metabolic products of acetate are CO₂ and H₂O, which are in equilibrium with bicarbonate via carbonic anhydrase activity.

Administration of sodium acetate increases the strong ion difference by net increase in cations, as acetate is metabolize, and leads to alkalemia.

Adverse events from sodium acetate infusion have been associated with its use as dialysate buffer: myocardial depression, hypotension, hypopnea leading to hypoxemia and hyperpyrexia. However, such adverse events have not been reported in toxicologic application.

Bottom line:

Sodium acetate can be administered safely in place of sodium bicarbonate if sodium bicarbonate is not available due to shortage.

Sodium acetate dose:

• Bolus: 1 mEq/kg over 15 – 20 min
• Infusion: 150 mEq in 1L D5%W @ twice maintenance rate   

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·       In the elderly, falling is the most common mechanism of injury
·       Unavoidable Risk factors: age 85 or older, male, Caucasian, history of falls
·       Other factors: alcohol consumption, polypharmacy
·       Mechanisms of fall:  slipping, tripping, stumbling
·       Physical exam to include: gait, balance, proprioception, vision, strength and cognitive function testing
·       Must consider neglect/abuse, affects 10% of seniors per year
·       Evaluate for anticoagulant use due to increased risk of intracranial injury
·       Use advanced imaging to identify occult hip fractures when clinically suspected and plain radiographs are negative

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Linezolid is a weak, nonselective monoamine oxidase inhibitor (MAOI). A recent FDA Drug Safety Communication released in March 2016 noted reports of serotonin syndrome associated with certain opioids, particularly fentanyl and methadone. Development of serotonin syndrome after concomitant administration of linezolid with other serotonergic agents has been reported. Due to a potential risk of serotonin syndrome, a patient on chronic methadone should not be started on concomitant linezolid unless they will be monitored.

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Question

Sepsis remains the most common cause of death in infants and children worldwide, with pneumonia being the most common cause of pediatric sepsis overall.

Strikingly, however, the mortality rate in pediatric sepsis is significant lower in children (10-20%) as compared to adults (35-50%).

The management of pediatric sepsis has been largely influenced by and extrapolated from studies performed in adults, in part due to difficulties performing clinical trial data in children with critical illness, including sepsis.

A major difference in management of children vs. adults with refractory septic shock with or without refractory hypoxemia from severe respiratory infection is the dramatic survival advantage of children when ECMO rescue therapy is used as compared to adults.

Bottom line: Consider ECMO for refractory pediatric septic shock with respiratory failure – in kids, survival is improved dramatically – consider it early!

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Children less than 5 years of age account for the majority of poisoning exposures in the United States. As expected, accessible household items are the most frequently reported exposures and include cosmetics and personal care products, household cleaning substances, medications, and foreign bodies. Opioids are responsible for the highest incidence of hospitalizations followed by benzodiazepines, sulfonylureas, and cardiovascular drugs (beta & calcium channel blockers, and centrally acting antiadrenergic agents).  Rise in buprenorphine use has led to significant increases in pediatric exposures. The most common sources of prescription medications were pills found on the ground, in a purse or bag, night stand, or pillbox. The 2015 American Association of Poison Centers Annual report lists 28 fatalities in children less than 5 year of age. Fatalities occurred from exposures to the following: narcotics (9), disc and button batteries (5), carbon monoxide (4), and other substances (10). 

Highlighted AAPC cases include:

•  20 month old with ingestion of 20 mm Lithuim disc battery with several previous ED visits for abdominal pain who developed an aorto-esophageal fistula 
• 13 month old with ingestion of unknown amount of salicylate pills 4 hours earlier with nausea and vomiting
• 2 year old with ingestion of 5 tablets of 30mg Oxycodone ER seen in ED and discharged 7 hours later. EMS called next morning found patient unresponsive and apneic
• 11 month old with ingestion of 1 unknown strength methadone pill found unresponsive and apneic at home

Poison prevention education of patients prescribed opioids or other highly toxic "one pill killers"  who have young children in their household is recommended and could be potentially life saving.

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·       Falls are the second leading cause of accidental or unintentional injury deaths worldwide.

·       Each year an estimated 424 000 individuals die from falls globally of which over 80% are in low- and middle-income countries.

·       Adults older than 65 suffer the greatest number of fatal falls.

·       37.3 million falls that are severe enough to require medical attention, occur each year.

·       Prevention strategies should emphasize education, training, creating safer environments, prioritizing fall-related research and establishing effective policies to reduce risk.

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DSI, Ketamine, and Apnea

• In recent years, delayed sequence intubation (DSI) with ketamine has been used in select patients to maximize preoxygenation and dinitrogenation. 
• Importantly, DSI is not well studied. In the only prospective trial of DSI, patients received approximately 1.4 mg/kg of ketamine.
• Driver, et al. report the abrupt onset of apnea in a patient who received a much lower dose of ketamine (25 mg) for DSI.
• Take Home Point: If DSI is a part of your preoxygenation armamentarium, apnea can occur even at low doses of ketamine.  Stand at the patient's bedside and be ready to immediately intubate the patient.

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Question

Physicians are often called upon to serve as a team physician for a local high school in an official or unofficial capacity.

To aid in preparedness for sport-related emergencies, multiple national organizations have defined institutional best practices.

Knowledge of the following 3 best practice recommendations is important before taking on the role of “Doc covering the game”

     1)The written Emergency Action Plan (EAP) – details the standard of emergency care at the particular venue.

     2)The availability of life saving equipment: AED – where is it, charged and working?

     3)Are the coaches trained in use of the AED and CPR. You can’t be everywhere and often multiple sporting events occur on campus simultaneously. It’s imperative that your first responder (coach or athletic trainer) can perform these tasks until you are able to respond

Please investigate these best practice recommendations before agreeing to serve as the physician for the local high school.

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Clinical signs and symptoms of clonidine overdose include CNS depression, bradycardia, and miosis. Other effects include early hypertension, followed by hypotension and respiratory depression, especially in children.

Although clonidine overdose in children is well described, frequency of clinical signs/symptoms in adults is not well characterized.

Recently, a retrospective study was performed in a hospital in Australia looking at clonidine overdose in adults.  

Among isolated clonidine overdose, patients experienced:

• GCS < 15: 55%
• GSS < 9: 5%
• Miosis: 25%
• Bradycardia (HR< 60): 68%
• Median HR: 48 (IQR: 40-62)
• Hypotension (SBP < 90 mmHg): 25%
• Median LOS: 21 hr (IQR: 11 – 27 hr)
• Intensive care: 23%
• No deaths

Bottom line:

1. The most common symtom of clonidicine overdose was bradycardia
2. Clonidine overdose results in non-life threatening but prolonged clinical effect in adult.

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• The incidence of stroke (both ischemic and hemorrhagic) in pregnant and peripartum women is three times age-matched controls. This increased risk is mostly in the 3rd trimester and up to 16 weeks postpartum. 

• Consider other causes of stroke:  posterior reversible encephalopathy syndrome (PRES), reversible cerebral vasoconstriction syndrome, cerebral venous sinus thrombosis and cardioembolic stroke from peripartum cardiomyopathy.

• CTs carry some risk due to the ionizing radiation, but with abdominal and pelvic shielding the exposure to the fetus is very low. MRIs do not carry that risk, but Gadolinium is absolutely contraindicated in pregnancy as it deposits in fetal tissue. 

• Pregnancy is a relative (not absolute) contraindication for tPA.

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While lung protective ventilatory strategies have long been accepted as vital to the management of patients undergoing mechanical ventilation, the translation of such practices to the Emergency Department is still limited and inconsistent.

Fuller et al employed a protocol ensuring lung-protective tidal volumes, appropriate setting of positive end-expiratory pressure, rapid weaning of FiO2, and elevating the head-of-bed. The authors found the number of patients who had lung protective strategies employed in the Emergency Department increased from 46.0% to 76.7%. This increase in protective strategies was associated with a 7.1% decrease in the rate of pulmonary complications (ARDS and VACs), 14.5% vs 7.4%, and a 14.3% decrease in in-hospital mortality, 34.1% vs 19.6%.

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Phenytoin is a first line anticonvulsant agent for most seizure disorders with the exception of absence and toxin-induced seizures. It has erratic gastrointestinal absorption with peak serum levels occurring anywhere from 3-12 hours following a single oral dose. 90% of circulating phenytoin is bound to albumin but only the unbound free fraction is active to cross cell membranes and exert pharmacological effect. Measured serum phenytoin levels reflect the total serum concentration of both the free and protein bound portions. Therapeutic range is between 10-20 mg/L. Free phenytoin levels are not often measured but are normally between 1-2 mg/L. Individuals with decreased protein binding (elderly, malnourished, hypoalbuminemia, uremia, and competing drugs) may have clincial toxicity despite a normal total phenytoin level. Toxicity consists of predominantly ocular and neurologic manifestations involving the vestibular and cerebellar systems:

Treatment of overdose is primarily supportive with serial drug level testing and neurologic exams. There is no evidence that gastrointestinal decontamination improves outcome. Routine cardiac monitoring is not necessary for overdose following oral ingestions. Cardiac toxicity is rarely seen and only with parenteral administration. 

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The World Health Organization (WHO) recently published their first ever list of antibiotic-resistant "priority pathogens".  These 12 families of bacterial pathogens have the potential to be a significant threat to human health.

These bacteria are divided in critical, high and medium priority pathogens. 

The critical pathogens requiring R & D for new antibiotics are:

1.     Acinetobacter baumannii, carbapenem-resistant

2.     Pseudomonas aeruginosa, carbapenem-resistant

3.     Enterobacteriaceae, carbapenem-resistant, ESBL-producing

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22yo college track athlete presents with 3 weeks of gradual onset groin and thigh pain, worse with running, better with rest.

Stress fractures are a common cause of groin pain in athletes, particularly in long distance runners

Fractures occur in the pubic rami and femoral neck 

Ask about a sudden change in training regimens

PE: check for tenderness to deep palpation over the pubic ramus. Ask athlete to stand and support full weight on affected leg or perform one legged hop on affected side. Pain out of proportion to physical examination findings. 

Imaging: XR usually negative. Bone scans can be positive as early as 4 to 8 days after symptom onset. MRI used to diagnose and rule out other causes of groin pain.

Treatment: Rest for 4 to 6 weeks. Consider making patient non weight bearing if walking causes pain especially with femoral neck fractures on the superior side. Inferior side neck fractures may benefit from prophylactic fixation.

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Preoxygenation in Critically Ill Patients

• Achieving adequate preoxygenation and denitrogenation prior to intubating critically ill patients can be challenging.
• Critically ill patients have physiologic alterations (i.e., derangements in oxygen consumption, anemia, reduced cardiac output, air space disease) that can markedly reduce safe apnea time.
• For patients with significant air space disease and shunt physiology, noninvasive ventilation (NIV) can decrease shunt fraction, increase functional residual capacity, improve PaO2, and lengthen safe apnea time.
• Importantly, NIV should be used for at least 3 minutes to achieve improvements in alveolar recruitment.
• It is also important to remove NIV just prior to larygnoscopy, as alveoli will begin to derecruit when NIV is removed.

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