Keywords: Anticholinergic, Plant (PubMed Search)
A 19 year old male presents confused and very agitated complaining of seeing things and stomach pain. His friends report he ingested a naturally occurring plant to get high a few hours ago but is having a "bad trip". His physical exam :
Temp 100.3, HR 120, RR 14, BP 130/88. Pulse Ox 98%.
Skin: Dry, hot , flushed
HEENT: Marked mydriasis 6mm
Abdomen: Distended tender suprapubic with absent bowel sounds,
Neuro: Extremely agitated pacing, no muscular rigidity.
What has he ingested and what is the treatment?
Datura stramonium, aka: Jimson Weed, flowers in the summer with white to violet trumpet petals, green irregular toothed leaves, and a green thorny round walnut sized seed pod (aka: thorn apple) the base of the stem. In the fall, the seed pods turn brown and split open to reveal chambers that are packed with dozens of small black seeds containing the anticholinergic tropane alkaloids, atropine, hyoscyamine, and scopolamine.
All parts of the plant are toxic and it has long been used in traditional medicine. Toxicity consists of anticholinergic toxidrome: Delirium and agitation, visual hallucinations, dry flushed skin, hyperthermia, mydriaisis, tachycardia, absent bowel sounds, urinary retention, remembered by the pneumonic "Red as a beet, hot as a hare, dry as a bone, blind as a bat, mad as a hatter, the bowel and bladder lose their tone, and the heart runs alone" . Toxicity is usually 12 hours but can be quite prolonged.
Treatment consists of :
-Gastric decontamination with activated charcoal and whole bowel irrigation for seed ingestion (seeds get caught up in gastric folds prolonging toxicity)
-IV Physostigmine, a reversible short acting acetylcholinesterase inhibitor increases acetylcholine at the synaptic clef, crosses the blood brain barrier, and is antidotal. Physostigmine has been demonstrated to be more effective and without significant complications when compared with benzodiazepines for the diagnosis and treatment of anticholinergic agitation and delirium. Usual dose is 0.5-2 mg with repeat dosages as needed.
Category: Critical Care
Sedating Mechanically Ventilated Patients
Keywords: Concussion, minor head injury, traumatic brain injury, mTBI (PubMed Search)
The Centers for Disease Control and Prevention recently released guidelines on the diagnosis and management of mild traumatic brain injury (mTBI**) among children. From 2005-2009, children made almost 3 million ED visits for mTBI. Based on a systemic review of the literature, the guideline includes 19 sets of recommendations on the diagnosis, prognosis, and management/treatment of pediatric mTBI.
1. Do not routinely image patients to diagnose mTBI (utilize clinical decision rules to identify children at low risk and high risk for intracranial injury (ICI), e.g. PECARN)
2. Use validated, age-appropriate symptoms scales to diagnose mTBI
3. Assess evidence-based risk factors for prolonged recovery. No single factor is strongly predictive of outcome.
4. Provide patients with instructions on return to activity customized with their symptoms (see CDC Resources below)
5. Counsel patients to return gradually to non-sports activities after no more than 2-3 days of rest.
A wealth for information and tools for provder and families can be found at:
www.cdc.gov/HEADSUP (including evaluation forms and care plans for providers)
**Although concussion, minor head injury, and mBI are frequently used interchangeably, they have different connotations which allows for misinterpretation and confusion. The guideline recommends the clinical use of the single term mild traumatic brain injury. This is defined as "an acute brain injury resulting from mechanical injury to the head from external physical forces including: (1) 1 or more of the following: Confusion or disorientation, loss of consciousness for 30 minutes or less, posttraumatic amnesia for less than 24 hours, and/or other transient neurologic abnormality such as focal signs, symptoms, or seizure; (2) Glasgow Coma Scale score of 13-15 after 30 minutes post injury or later upon presentation for healthcare
Diagnosis and management of mild traumatic brain injury in children: A systemic review. Lumba-Brown A, Yeates KO, Sarmiento K, Breiding MJ, Haegerich TM, Gioia GA, Turner M, Benzel EC, Suskuer SJ, Giza CC, Joseph M,Broomand C, Weissa B, Gordon W Wright DW, Moser RS, McAvoy K, Ewing-Cobbs L, Duaime AC, Putukian M, Holhouse B, Paulk D, Wade SL, Herig SA, HalsteadM, Keenan H, Choe M, Christia CW, Gusiewic K, Raksin PB, Gregory A, Mucha A, Taylor HG, Callahan JM, DeWtt J, Collins MW, Kirkwood MW, Ragheb J, Ellenbogen RG, Spinks TJ, Ganiats TG, Sabelhaus LJ, Altenhofen K, Hoffman , Getchius T, Gronseh G,Donnell Z, O'Connor RE, Timmons SD JAMA Pediatr 2018 Sept 4.
Keywords: anaphylactoid reaction, IV NAC (PubMed Search)
Analphylatoid reaction is caused by non-IgE mediated histamine released. Intravenous N-acetylcysteine (NAC) infusion is well known to cause analphylatoid reaction. However, it’s incidence is unknown.
Recently, a large retrospective study of all patients who received 21-hour IV NAC in 34 Canadian hospitals (1980 to 2005) was performed.
Anaphylactoid reaction was documented in 528 (8.2%) of 6455 treatment courses
Over 90% patients developed analphylatoid reaction within 5 hours.
Onset of reaction:
Administered medication for treatment
Patient characteristics that were associated with higher incidence of Anaphylactoid reaction includes
Yarema M et al. Anaphylactoid reactions to intravenous N-acetylcysteine during treatment for acetaminophen poisoning. J Med Toxicol 2018: Jun;14(2):120-127. doi: 10.1007/s13181-018-0653-9. Epub 2018 Feb 8.
Category: Critical Care
Keywords: acidosis, acidemia, sodium bicarbonate, shock (PubMed Search)
The recently published BICAR-ICU study looked at the use of bicarb in critically ill patients with severe metabolic acidemia...
Consider administration of sodium bicarbonate for your critically ill ED patients with severe metabolic acidosis and AKI, especially if acidosis &/or renal function is not improved with usual initial measures (such as IVF, etc).
*Acute Kidney Injury Network Staging Criteria
Jaber S, Paugam C, Futier E, et al. Sodium bicarbonate therapy for patients with severe metabolic acidaemia in the intensive care unit (BICAR-ICU): a multicentre, open-label, randomised controlled, phase 3 trial. Lancet. 2018;392(10141):31-40.
Keywords: Ulnar nerve (PubMed Search)
Tests for motor weakness of the Ulnar nerve
Patient asked to hold piece of paper in both hands, grasping with the thumb and radial side of index finger of both hands
Examiner then pulls on the paper
Test is positive if patient flexes the thumb IP join in an attempt to hold onto paper
Category: Critical Care
Does Lactated Ringer's Raise Serum Lactate?
Zitek T, et al. Does intraveneous lactated ringer's solution raise serum lactate? J Emerg Med. 2018; 55:313-8.
Keywords: wounds, trauma, procedure (PubMed Search)
Many elderly patients have thin skin making suture repair of lacerations difficult. Consider using Steri-Strips™ in combination with sutures to close fragile skin tears.
1. Apply Steri-Strips™ perpendicular to the wound in order to approximate skin edges.
2. Place sutures through both the applied Steri-Strips™ and skin and knot the suture.
This technique will help prevent the suture from tearing the skin as the tension of the suture will be distributed across the surface area of the Steri-Strips™.
Davis M, Nakhdjevani A, Lidder S. Suture/Steri-Strip Combination for the Management of Lacerations in Thin-Skinned Individuals. The Journal of Emergency Medicine. 2011;40(3):322-323. doi:10.1016/j.jemermed.2010.05.077.
Category: Pharmacology & Therapeutics
Keywords: Sepsis, Antibiotics, CMS, Core Measures (PubMed Search)
The Centers for Medicare and Medicaid Services (CMS) require broad spectrum antibiotics to be administered within 3 hours of presentation of sepsis to be in compliance with the sepsis measure.
Not only do the antibiotics that are chosen determine compliance with this measure, but the order in which antibiotics are given can also significantly affect compliance.
According to CMS, for combination antibiotic therapy, both antibiotics must be started within the three hours following presentation; however, they do not need to be completely infused within this time frame.
Combination therapy typically includes a monotherapy antibiotic (see list in detailed information below) plus vancomycin (daptomycin or linezolid could also be used).
So which antibiotic should be given first?
If a monotherapy antibiotic is given first within the 3 hours of presentation, then compliance for the sepsis measure is met. These antibiotics cover a broader range of bacteria and are typically infused over ~30 minutes, which allows plenty of time for your second antibiotic to be initiated.
If vancomycin is given first, compliance with this measure can become difficult. First, vancomycin has a narrower spectrum of activity and is not a monotherapy antibiotic. Second, vancomycin infusion rates range from 1 to 2 hours. Given that antibiotics are usually given after sepsis is flagged, this infusion rate only gives a short period of time for the second antibiotic to be initiated. Thus, vancomycin should almost always be the second antibiotic infused.
In addition, patients may also have limited intravenous access or antibiotics may not be compatible with resuscitation fluids. All of these factors together must be considered when trying to gain compliance with this measure.
Administer monotherapy antibiotics (e.g. piperacillin/tazobactam and cefepime) prior to administering vancomycin in your septic patients to improve compliance with the sepsis measure.
Specifications Manual for National Hospital Inpatient Quality Measures v5.4. The Joint Commission. https://www.jointcommission.org/specifications_manual_for_national_hospital_inpatient_quality_measures.aspx. Updated December 29, 2017. Accessed August 31, 2018.
Bachur, R. Comparison of acute treatment regimens for migraine in the emergency department. Pediatrics.2015;135(2)232-238.
Gelfand, A. Treatment of pediatric migraine in the emregency department. Ped Neuro.2012;47(4)233-241.
Kacperski, J. The optimal management of headaches in chidlren and adolescents. Ther Adv Neuro Disor. 2016;9(1)53-68.
Sheridan, D. Pediatric Migraine: Abortive treatment in the emergency department. Headache. 2014;54(2):235-245.
Keywords: Weakness (PubMed Search)
A 68 year old male presents to the ED complaining of weakness to his legs. He states today his yard chores took him over 2 hours to complete instead of the usual 15-20 minutes due need to take frequent breaks for rest due to leg pain. He denied any chest pain or shortness of breath. Past medical history included hypercholesteremia, HTN, and CAD. He is taking aspirin and recently started on rosuvastatin.
His physical exam was unremarkable.
Results showed normal EKG and CBC. Bun was 70, Creatinine was 3.4, and CPK of 1025.
This patient has statin induced rhabdomyolysis and acute renal failure.
Take Home Points:
Category: Airway Management
Keywords: foot, necrosis (PubMed Search)
Osteonecrosis of the tarsal navicular bone
Affects children ages 4 to 7
4x more likely in males
Can be painless or present with arch/midfoot pain and a limp (usually activity related)
Usually unilateral but can be bilateral (in up to 25%)
PE: Tenderness to palpation over the length of the arch esp the medial navicular
Swelling, warmth, redness
-Can be misdiagnosed as an infection
X-ray: Sclerosis, collapse/flattening or fragmentation of navicular
Treatment: Walking boot or short leg cast
Keywords: naloxone dose, recurrence of opioid toxicity (PubMed Search)
Various intial doses of naloxone (0.4 to 2 mg) are administered to reverse the signs and symptoms of opioid toxicity. However, there is limited data regarding the duration of action of naloxone is correlated to the administered dose.
A recently published retrospective study investigated whether initial naloxone doses (IV), low-dose (0.4 mg) vs. high-dose (1-2 mg), lead to different time to recurrence of opioid toxicity.
Study sample: 274 patient screened but 84 patients were included.
Higher rate of adverse effects (withdrawal symptoms - vomiting, agitation, tachycardia, etc.) were observed in high-dose group (41% vs. 31%) but this was not statistically signficant.
Wong F et al. Comparison of lower-dose versus higher-dose invetravenous naloxone on time to recurrence of opioid toxicity in the emergency department. Clin Toxicol (Phila) 2018 Jul 23:1-6. doi: 10.1080/15563650.2018.1490420. [Epub ahead of print]
Keywords: shingles, weakness, infection (PubMed Search)
Category: Critical Care
Critical Post-Arrest Interventions
Walker AC, Johnson NJ. Critical care of the post-cardiac arrest patient. Cardiol Clin. 2018; 36:419-428.
Keywords: Sedation, NPO time, pediatrics (PubMed Search)
Is there an association between pulmonary aspiration, vomiting or any serious adverse event and the preprocedural fasting time?
The odds ratio of any adverse event did not increase significantly with each additional hour of fasting duration for both solids and liquids.
The guidelines set by the American Society of Anesthesiology for fasting include a minimum of 2 hours for clear liquids, 4 hours for breast milk, 6 hours for formula and light meals and 8 hours for solid meals containing fatty foods or meat.
This was a secondary analysis of a multicenter prospective cohort study of children 0-18 years who received procedural sedation in 6 Canadian pediatric emergency departments from 2010-2015. 6183 children were included with 99.7% meeting ASA 1 or 2 categories. 2974 patients did not meet the American Society of Anesthesiology fasting guidelines for solids and 510 patients did not meet the fasting guidelines for liquids. The overall incidence of adverse events was 11.6%. There were no cases of pulmonary aspiration. There was a total of 717 adverse events. 315 events were vomiting. Oxygen and vomiting were the most common adverse events.
Association of Preprocedural Fasting with Outcomes of Emergency Department Sedation in Children. JAMA Pediatrics. Published online May 18, 2018.
Category: Critical Care
Keywords: Resuscitation, OHCA, prehospital medicine, cardiac arrest, epinephrine (PubMed Search)
The highly-awaited PARAMEDIC2 trial results are in:
Interestingly, the authors also queried the public as to what mattered to them most:
A Few Things:
Perkins GD, Ji C, Deakin CD, et al. A Randomized Trial of Epinephrine in Out-of-Hospital Cardiac Arrest. N Engl J Med. 2018. doi: 10.1056/NEJMoa1806842.
Keywords: Heat illness (PubMed Search)
Exertional Heat Stroke (EHS)
With football preseason starting across the country, it is important to review this topic
EHS is a medical emergency resulting from progressive failure of normal thermoregulation
EHS has a high mortality
-2nd most common cause of death in football players
History and Exam
Hyperthermia/Core temperature greater than 40°C (104°F)
Initial profuse sweating with eventual cessation of sweating with hot, dry skin
CNS dysfunction – disorientation, confusion, dizziness, inappropriate behavior, difficulties maintaining balance, seizures, coma
Other: Tachycardia/hyperventilation, fatigue, vomiting, headache
Multi-organ involvement: CNS, cardiac damage, renal failure, hepatic necrosis, muscle (rhabdomyolysis), GI (ischemic colitis), heme (DIC), ARDS
The single most important thing you can do on the field is recognize this entity. Early recognition leads to earlier initiation of treatment which is life saving.
Rapid cooling is key. This is often stated but what this means is whole body immersion in ice water. This should be available and ready for all summer practices.
The temperature needs to be lowered to below 39°C (102°F)
Also consider a cooling blanket, fanning, ice to body
DO NOT put them on ambo without initiating cooling!!!
Sustaining heat injury predisposes to subsequent heat related injury
Keywords: cerebral venous thrombosis, CVT, anticoagulation, low molecular weight heparin, LMWH, UFH (PubMed Search)
Bottom Line: LMWH appear to be similar in efficacy and safety compared with UFH for the management of CVT.
Al Rawahi B, Almegren M, Carrier M. The efficacy and safety of anticoagulation in cerebral vein thrombosis: a systematic review and meta-analysis. Thromb Res 2018;169:135-9. [Epub ahead of print]
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Category: Critical Care
Respiratory alkalosis is the most common acid-base disturbance in acute severe asthma.
Lactic acidosis is also extremely common, developing in up to 40%. This may be related to:
- tissue hypoxia
- increased respiratory muscle usage related to work of breathing
- beta agonist therapy
The first report of beta agonist administration associated with hyperlactatemia was in 1981 in patients treated for preterm labor with terbutaline. Since then, numerous case reports and studies have linked IV and inhaled beta agonist administration with the development/worsening of lactic acidosis in severe asthmatics in the ICU and in the ED.
The exact mechanism is unclear, but is thought to be related to adrenergic stimulation leading to increased conversion of pyruvate to lactate.
In a study published in Chest in 2014, investigators evaluated plasma albuterol levels and serum lactate levels, as well as FEV1.
They found plasma albuterol levels correlated with lactate concentration and maintained significant association after adjusting for asthma severity (suggesting the association was independent of work of breathing/respiratory muscle usage).
Furthermore, several reports have suggested that dyspnea may improve in patients with elevated lactate and acidosis after beta agonists are withheld.
Take Home Points:
- Beta agonist therapy may contribute to lactic acidosis.
- Lactic acidosis may contribute to respiratory distress.
- In patients on prolonged, high-dose beta agonist therapy, consider checking a serum lactate periodically. If elevated, consider whether worsening lactic acidosis is contributing to respiratory distress and contemplate transitioning to less frequent treatments.
-Patients with severe asthma exacerbation and elevated serum lactate must have thorough evaluation for true tissue hypoxia/hypoperfusion. **Beta agonist associated hyperlactatemia should be a diagnosis of exclusion.**
Raimondi GA, Gonzalez S, Zaltsman J, Menga G, Adrogué HJ. Acid–base patterns in acute severe asthma. J Asthma. 2013;50(10):1062-1068. doi:10.3109/02770903.2013.834506.
Rabbat A, Laaban JP, Boussairi A, Rochemaure J. Hyperlactatemia during acute severe asthma. Intensive Care Med. 1998;24(4):304-312. http://www.ncbi.nlm.nih.gov/pubmed/9609407.
Rodrigo GJ, Rodrigo C. Elevated plasma lactate level associated with high dose inhaled albuterol therapy in acute severe asthma. Emerg Med J. 2005;22(6):404-408. doi:10.1136/emj.2003.012039.
Lewis LM, Ferguson I, House SL, et al. Albuterol Administration Is Commonly Associated With Increases in Serum Lactate in Patients With Asthma Treated for Acute Exacerbation of Asthma. Chest. 2014;145(1):53-59. doi:10.1378/chest.13-0930.
Koul PB, Minarik M, Totapally BR. Lactic acidosis in children with acute exacerbation of severe asthma. Eur J Emerg Med. 2007;14(1):56-58. doi:10.1097/01.mej.0000224430.59246.cf.