Category: Critical Care
Keywords: VAD, LVAD, Heart Failure (PubMed Search)
It's important to remember the differential for the patient with Ventricular Assist Device (VAD) difficulties, as these patients are likely to show up in your ED.
1) Assess the patient as you usually would (signs of life, mental status, breathing, arrhythmias on monitor, etc). Listen for a hum over the chest. Don't expect to feel a pulse.
2) Look at the VAD including controller, driveline, and power source for alarms, disconnections, signs of infection, and other obvious issues.
3) Look at the power (displayed flow), pulsatility index, and pump speed on the controller to help determine the cause of the issue (see attached chart). Once you have a suspected etiology, typical management of these issues is usually similar to non-VAD patients (i.e. gentle IVF for hypovolemia, vasodilators if low flow is due to afterload/hypertension, defibrillation/CPR for arresting pts, etc).
Don't forget to call your VAD coordinator when able. Consider a-line placement for precise evaluation of blood pressure (focus on MAP).
Bottom Line: Consider obstruction/thrombosis, bleeding, infection, hypovolemia, afterload/hypertension, arrhythmia, worsening LV function, and suction events when troubleshooting VADs. The power, pulsatility index, and pump speed help differentiate these conditions.
Category: Pharmacology & Therapeutics
Keywords: droperidol (PubMed Search)
Droperidol is a butyrophenone with primary action as a dopamine D2 receptor antagonist. Historically, it has been used to treat a variety of conditions from nausea and headaches to acute agitation. In 2001, the FDA issued a black box warning for risk of cardiac arrhythmias. Following this warning, droperidol was on national shortage for several years, further limiting its use.
Several months ago, droperidol returned to the US market and is available at some institutions. Below is a refresher on dosing and monitoring. Similar to haloperidol, droperidol can cause extrapyramidal symptoms. Consider pre-treatment with diphenhydramine.
Nausea and vomitting: 1.25 mg IV
Headache: 2.5 mg IV, 5 mg IM
Acute agitation: 5mg IM/IV
QTc prolongation is still a concern, especially at higher doses. If using doses > 2.5mg, or using repeated doses, obtain an ECG to ensure safe use of this medication. If the QTc is greater than 440 msec for males or 450 msec for females, droperidol is not recommended. There is little data regarding the risk with lower doses. Utilize clinical judgement and assess patient risk factors.
Perkins J, et al. American Academy of Emergency Medicine position statement: Safety of droperidol use in the emergency department. J Emerg Med. 2014;49(1): 91-97.
Keywords: nitrous oxide, neurotoxicity (PubMed Search)
Numerous different household products can potentially be misused/abused. One such product is whipped cream charger/propellant that contains nitrous oxide.
Acute toxicity produce dose dependent response
Chronic toxicity causes myeloneuropathy (demyelination of the dorsal and lateral columns of the spinal cord) due to vitamin B12 deficiency
Category: Critical Care
Keywords: Atrial Fibrillation, sepsis, critical care, cardioversion, beta blockers, calcium channel blockers, rate control, rhythm control (PubMed Search)
One third of your critically ill patients will have atrial fibrillation.
More than one third of those patients will develop immediate hypotension because of it.
More than one in ten will develop ischemia or heart failure because of it.
This is what you should know for your next shift:
#1 Don't wait to use electricity. If your patient is hypotensive or ischemic because of atrial fibrillation, you do not need to wait for anticoagulation before you cardiovert.
#2 Electricity buys you time to load meds. Fewer than half of patients you cardiovert will be in sinus rhythm an hour later and fewer than a quarter at the end of a day.
#3 There is no perfect rate control agent. Beta blockers have a lower mortality in A-fib from sepsis. Esmolol has the benefit of being short-acting if you cause hypotension. Diltiazem has better sustained control than amiodarone or digoxin.
#4 There is no perfect rhythm control agent. Magnesium is first-line in guidelines. Amiodarone can be used even when there is coronary artery or structural heart disease.
#5 Anticoagulation is controversial. In sepsis, anticoagulation does not reduce the rate of in-hospital stroke, but does increase the risk of bleeding. Use with caution if cardioversion isn't planned.
Bosch N, Cimini J, Walkey A. Atrial Fibrillation in the ICU. CHEST 2018; 154(6):1424-1434
There is no standardized national reporting of dog bites in the US. Based on the reported figures, it is estimated that 2% of Americans are bitten annually, and children are affected disproportionately. With kids, it's usually the family dog, and occurs at home.
To avoid infection, usually from Pasturella species, many of us were taught never to primarily repair dog bites by suturing, and to always prescribe prophylactic antibiotic coverage with amoxicillin-clavulanate. However, the literature recommends otherwise in certain cases.
Bite wounds to the face and hands should have special considerations. In general, face wounds heal with lower rates of infection, but provide the greatest concern for cosmetic appearance. Hand wounds have notoriously higher rates of infection.
The latest recommendations for dog bites are as follows:
1. All dog bites should be copiously irrigated under high pressure.
2. Dog bites to the face should be primarily repaired when <8 hours old, as infection rates are not significantly different and cosmesis is greatly improved.
3. Injuries to the hands should be left open, unless function is in jeopardy or there are neurovascular concerns.
4. Prophylactic antibiotics do not always have to be prescribed, especially in low risk patients. Examples of high risk patients include, but are not limited to: primarily repaired bites, injuries in the hand, >8 hours old, deep or macerated or multiple bites, and the immunocompromised.
Paschos NK et al. Primary closure versus non-closure of dog bite wounds. A randomised controlled tira. Injury 2014 45(1): 23l7-40
Chen, HH et al. Analysis of Pediatric Facial Dog Bites. Cranomaxillofac Trauma Reconstr. 2013 Dec; 6(4):225-232
Ellis, R; Ellis, C (2014). "Dog and cat bites". American Family Physician. 90 (4): 239–43.
Keywords: Intracerebral hemorrhage, ICH, BP, variability, outcome (PubMed Search)
Bottom Line: Reduced SBP variability is associated with improved outcomes in ICH.
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Category: Critical Care
Critical Care Management of AIS
Smith M, Reddy U, Robba C, et al. Acute ischaemic stroke: challenges for the intensivist. Intensive Care Med. 2019; epub ahead of print.
Keywords: Foot, instability, dislocation (PubMed Search)
The Lisfranc ligament is critical for stabilization of the midfoot arch and the 2nd MT
Injuries can range from mild (sprains) to severe (gross dislocation)
Injury may be purely ligamentous injuries or a fracture-dislocations
Difficult diagnosis to make
Mechanisms: MVAs, fall from height or athletic injuries
Common athletic mechanism: Axial load to a hyperplantar flexed forefoot
Injury severity is often underestimated
Severe pain and inability to weight bear
Plantar bruising and bruising throughout midfoot
No specific tests as exam is limited due to pain
Midfoot stress tests
-Often positive but unlikely to be allowed by patient due to pain
Midfoot instability test
Grasp metatarsal heads and apply dorsal force to forefoot.
Other hand palpates the TMT joints and feels for dorsal subluxation
Keywords: NV exam, neurovascular, upper extremity injury, orthopedics, hand, fracture, supracondylar (PubMed Search)
Keywords: vaping, THC, e-cigarette, pulmonary injury (PubMed Search)
Center for Disease Control and Prevention (CDC) recently issued alerts regarding cases of pulmonary illnesses that may be linked to "vaping" (in 15 states with 149 possible cases). These cases are still under investigation but all cases reported vaping weeks/months prior to hospitalization.
Most cases involve young adults who have been using THC-containing products
Common complaints included
What to do:
Category: Critical Care
Keywords: Torsades de pointes, QT prolongation, antibiotics (PubMed Search)
A new study confirmed the previously-known antibiotics to be associated with Torsades de pointes and QT prolongation (Macrolides, Linezolid, Imipenem and Fluoroquinolones). However, this study found new association between amikacin and Torsades de pointes/QT prolongation.
The authors queried the United States FDA Adverse Event Reporting System (FAERS) from 01/01/2015 to 12/31/2017 for reports of Torsade de points/QT prolongation (TdP/QT).
Reporting Odd Ratio (ROR) was calculated as the ratio of the odds of reporting TdP/QTP versus all other ADRs for a given drug, compared with these reporting odds for all other drugs present in FAERS
FAERS contained 2,042,801 reports from January 1, 2015 to December 31, 2017. There were 3,960 TdP/QTP reports from the study period (0.19%).
Macrolides ROR 14 (95% CI 11.8-17.38)
Linezolid ROR 12 (95% CI 8.5-18)
Amikacin ROR 11.8 (5.57-24.97)
Imipenem-cilastatin ROR 6.6 (3.13-13.9)
Fluoroquinolones ROR 5.68 (95% CI 4.78-6.76)
These adverse events are voluntary reports
There might be other confounded by concomitant drugs such as ondansetron, azole anti-fungals, antipsychotics.
Teng C, Walter EA, Gaspar DKS, Obodozie-Ofoegbu OO, Frei CR. Torsades de pointes and QT prolongation Associations with Antibiotics: A Pharmacovigilance Study of the FDA Adverse Event Reporting System. Int J Med Sci. 2019 Jun 10;16(7):1018-1022.
Keywords: GSW, mass shooting, bleeding (PubMed Search)
Gunshot injuries are a leading cause of morbidity and mortality in the pediatric population. The Pediatric Trauma Society supports the use of tourniquets in severe extremity trauma. The Combat Application Tourniquet (CAT) that is commonly used in adults has not been prospectively tested in children. This study used 60 children ages 6 through 16 years and applied a CAT to the upper arm and thigh while monitoring the peripheral pulse pressure by Doppler. The CAT was successful in occluding arterial blood flow in all of the upper extremities and in 93% of the lower extremities.
Bottom line: The combat application tourniquet can stop arterial bleeding in the school aged child.
Harcke et al. Adult tourniquet use for school-age emergencies. Pediatrics. 2109; 143 (6) e:20183447.
Keywords: drug-induced liver injury (PubMed Search)
Direct hepatotoxicity from a drug is predictable and dose-dependent.
Most commonly implicated agents include:
On the contrary, idiosyncratic prescription drug-induce liver injury is rare, unpredictable and not related to dose.
Most commonly implicated agents are:
Category: Critical Care
The Kidney Transplant Patient in Your ED
Darmon M, Canet E, Ostermann M. Ten tips to manage renal transplant recipients. Intensive Care Med. 2019;45(3):380-383.
Keywords: Anterior knee pain (PubMed Search)
-A painful impairment of knee function resulting from thickened and inflamed synovial folds
Plicae are embryologic remnant inward folds of the synovial lining present in most knees
Most plica are asymptomatic
A pathological synovial plica can become inelastic, thickened and fibrotic. It may bowstring across the femoral trochlea at 70 to 100 degrees of knee flexion
Can be a cause of anterior knee pain/mechanical Sxs
Medial patellar plica most commonly involved
Hx: Snapping sensation, pain w/ sitting or repetitive activity
Anterior knee pain, clicking, clunking, and a popping sensation on knee loading activity such as squatting/stairs or with prolonged sitting
Many present with history of blunt trauma to the anterior knee
PE: A taut band of tissue that reproduces concordant pain with palpation
Tenderness in the medial parapatellar region
Painful, palpable medial parapatellar cord
-This can be rolled and popped beneath the examiners finger
The knee may be tender to the touch, swollen, and stiff
Can be difficult to distinguish from other intra-articular conditions such as meniscal tears, articular cartilage injuries, or osteochondral lesions,
The examiner can then palpate for the plica by rolling one finger over the plica fold, which is located around the joint lines in anterior knee compartment
Lee et al., 2017. Surg J. Synovial Plica Syndrome of the Knee: A Commonly Overlooked Cause of Anterior Knee Pain.
Category: Critical Care
Keywords: mechanical ventilation, respiratory failure, obstructive lung disease, asthma exacerbation, COPD (PubMed Search)
Managing the intubated patient with exacerbation of severe obstructive lung disease, especially asthma, can be very challenging as it carries higher risks of barotrauma due to higher pulmonary pressures and circulatory collapse due to auto-PEEP and decreased venous return. When measures such as medical therapy and noninvasive positive-pressure ventilation fail to prevent intubation, here are some tips to help:
1. Utilize a volume control ventilation mode to ensure a set tidal volume delivery / minute ventilation, as pressure-targeted modes will be more difficult due to the high pulmonary pressures in acute obstructive lung disease.
2. Set a low RR in order to allow for full exhalation, avoiding air-trapping / breath-stacking and circulatory collapse due to decreased venous return. This may require deep sedation and potentially paralysis.
3. Increase your inspiratory flow by shortening your inspiratory time (thereby increasing your time for exhalation.
4. Monitor for auto-PEEP:
5. Peak inspiratory pressures will be high -- what is more important is the plateau pressure, measured by performing an inspiratory hold at the end of inspiration. Provided your plateau pressure remains <30, you don't need to worry as much about the peak pressure alarms.
6. If your patient acutely decompensates in terms of hemodynamics and oxygenation -- first attempt to decompress their likely auto-PEEPed lungs by popping them off the ventilator and manually press on their chest to assist with exhalation of stacked breaths allowing venous return to the heart.
Category: Pharmacology & Therapeutics
Keywords: DKA, SGLT2 Inhibitors (PubMed Search)
The American Diabetes Association requires a plasma glucose concentration greater than 250 mg/dL to diagnose diabetic ketoacidosis (DKA). However, with the new diabetic agents this is not always the case. With the introduction of SGLT2 inhibitors (canagliflozin [Invokana], dapagliflozin [Farxiga], empagliflozin [Jardiance]) there have been reported cases of DKA and patients being euglycemic.
Take Home Point
Patients with a low/normal blood glucose can still have DKA. Especially if they are taking newer medications, such as the SGLT2 inhibitors.
AE Kitabchi, GE Umpierrez, JM Miles, JN Fisher. Hyperglycemic Crises in Adult Patients With Diabetes. Diabetes Care 2009;32:1335-1343.
U.S Food and Drug Administration. FDA warns that SGLT2 inhibitors for diabetes may result in a serious condition of too much acid in the blood. https://www.fda.gov/media/92185/download. Accessed August 3, 2019.
Keywords: hematologic toxicity, copperhead envenomation, bleeding (PubMed Search)
Hematologic toxicity (coagulopathy/bleeding) can occur with pit viper envenomation. Copperhead is the most commonly implicated pit viper envenomation in the U.S. However, the prevalence of hematologic toxicity from copperhead envenomation is variable, possibly due to regional variation in venom potency and species misidentification.
An observation study was performing using multi-center (Virginia Commonweath university, University of Virginia Medical Center and Eastern Virginia Medical medical center) electronic hospital/medical records (Jan 1, 2006 to Dec 31, 2016) of suspected copperhead bites. Authors state that copperhead snakes are "nearly exclusively endemic" to the VCU and UVA medical center region.
388 patients were identified but 244 met inclusion/exclusion criteria.
Hematologic toxicity: 14%
In a small sample of copperhead envenomation in Virginia, “subtle” hematologic abnormalities were observed but clinically significant hematologic toxicity was not observed (i.e. bleeding)
Wills BK et al. Prevalence of hematologic toxicity from copperhead envenomation: an observational study. Clin Toxicol. 2019. DOI: 10.1080/15563650.2019.1644346
Category: Critical Care
Keywords: Mechanical Ventilation, Intubation, Extubation, RSBI (PubMed Search)
With increasing critical care boarding and the opioid crisis leading to more intubations for overdose, extubation - which was once a very rare event in the ED - is taking place downstairs more often. Prolonged mechanical ventilation is associated with a ton of complications, so it's important for the ED physician to be comfortable assessing extubation readiness. There is no single accepted set of criteria, but most commonly used are some variant of the following:
If the above criteria are met, two additional tests are frequently considered:
And don't forget to consider extubating high risk patients directly to BiPAP or HFNC!
Bottom Line: For conditions requiring intubation where significant clinical improvement may be expected while in the ED (e.g. overdose, flash pulmonary edema, etc), be vigilant about, and have a system for, assessing readiness for extubation.
1. Souter MJ, Manno EM. Ventilatory management and extubation criteria of the neurological/neurosurgical patient. The Neurohospitalist. 2013;3(1):39-45. doi:10.1177/1941874412463944
2. Thille AW, Richard J-CM, Brochard L. Concise Clinical Review The Decision to Extubate in the Intensive Care Unit. doi:10.1164/rccm.201208-1523CI
3. Ouellette DR, Patel S, Girard TD, et al. Liberation From Mechanical Ventilation in Critically Ill Adults: An Official American College of Chest Physicians/American Thoracic Society Clinical Practice Guideline: Inspiratory Pressure Augmentation During Spontaneous Breathing Trials, Protocols Minimizing Sedation, and Noninvasive Ventilation Immediately After Extubation. Chest. 2017;151(1):166-180. doi:10.1016/j.chest.2016.10.036
Keywords: Bone stress reaction, fracture, overuse injury (PubMed Search)
Bone stress injury (BSI) in Adolescents
A BSI occurs along a pathology continuum that begins with a stress reaction and may progress all the way to a stress fracture.
Difficult to diagnose clinically.
Identifying risk factors as part of the history is very important.
Common sites for BSI are most frequently in the lower extremity and include the tibia, fibula, tarsals and metatarsals, calcaneus, and femur.
When considering this in an ED setting, image the involved area and if there is no fracture, advise discontinuing the activity until time of PCP/sports medicine follow up. For those with rest pain, pain with minimal weight bearing or in whom a fracture was suspected but not present, consider providing a walking boot or crutches.
BSIs occur more frequently in young athletes than in adults.
Almost 50% of BSIs occur in those younger than 20 years of age
Primary care and sports medicine providers are seeing more of these patients due to many factors.
Year-round training, sports specialization at younger ages and increase in training intensity/duration contribute to the increase incidence in adolescents.
Not surprisingly, participation in organized sports as an adolescent is a known risk factor.
Just as a change in sporting level from high school to college is a known risk factor for BSI, young “gifted” athletes who are promoted to competing with the varsity team may be at similar risk.
Shin pain lasting more than 4 weeks may represent a unique subset of MSK pain complaints increasing risk of BSI.
A prior history of BSI is a strong predictor of future BSI.
Inquire about night pain, pain with ambulation, and pain affecting performance.
Athletes with BSIs have a significantly lower BMI than controls (<21.0 kg/m2).
Athletes with BSIs sleep significantly less than controls.
Athletes with BSIs have significantly lower dairy intake than controls.
Inquire about components of the female athlete triad (low energy availability, menstrual dysfunction and low bone mineral density)
Nussbaum et al., 2019. Identifying Factors That Contribute to Adolescent Bony Stress Injury in Secondary School Athletes: A Comparative Analysis With a Healthy Athletic Control Group. Sports Health.