Category: Infectious Disease
Keywords: clostridium difficile, antibiotics, vancomycin (PubMed Search)
Initial episode, non-severe
WBC ≤ 15,000 AND SCr <1.5
If above agents unavailable, metronidazole PO 500mg 3x daily
Initial episode, severe
WBC ≥ 15,000 OR SCr >1.5
Initial episode, fulminant
Hypotension, shock, ileus, megacolon
McDonald LC, Gerding DN, Johnson S, et al. Clinical Practice Guidelines for Clostridium difficile Infection in Adults and Children: 2017 Update by the Infectious Diseases Society of America (IDSA) and Society for Healthcare Epidemiology of America (SHEA). Clinical Infectious Diseases. 2018;66(7):e1-e48.
Keywords: Muscle pain, exercise (PubMed Search)
Delayed Onset Muscle Soreness (DOMS), aka “muscle fever”
Muscle pain and weakness following unfamiliar exercise
Occurs after high force, novel (unaccustomed) eccentric muscle contractions
Occasionally isometric in an extended position
Eccentric exercise – controlled elongation
Slowly lowering yourself to start position doing pullups for example
Time of onset
Begins 6 to 12 Hours after exercise, Peaks 2-3days post and resolves in 5-7 days
Speed of onset and severity are often related
How do you know if you have it?
Much like the flu, you know it when you have it. The simple act of getting out of a car, sitting down or walking down stairs is excruciatingly painful.
Exact cause is unknown. Thought to be due to sarcolemma damage leading to intra cellular calcium release and activation of proteolytic enzymes. Creatine kinase leaks from muscle cells into plasma attracting inflammatory cells.
Best treatment is prevention: Repeated bout effect – a bout of eccentric or isometric exercise can prevent DOMS from the same exercise for 4-12 weeks.
Stretching before exercise has not been shown to be effective prevention
Other modalities: rest, ice, heat, massage, electrical stimulation
Eccentric exercises or novel activities should be introduced progressively over a period of 1 or 2 weeks at the beginning of the sporting season or the start of a new, novel exercise routine. For example, not starting the Insanity day one workout without “pretraining.” This will reduce the level of physical impairment and/or training disruption and lead to gains with much less pain.
Keywords: transaminitis, delayed acetaminophen toxicity, rhabdomyolysis (PubMed Search)
Elevated transaminases are found in both rhabdomyolysis and delayed acetaminophen (APAP) toxicity. Establishing the cause of elevated transaminase can be difficult when there is unclear history of acetaminophen ingestion.
A retrospective study of patients with delayed acetaminophen toxicity or rhabdomyolysis from 2006 to 2011 was recently published.
The authors compared AST/ALT, CK/AST and CK/ALT ratio of
Keywords: infarct, paralysis, numbness (PubMed Search)
An infarct of the spinal cord is technically considered a stroke
The most common risk factor is a recent aortic surgery. Can also occur with straining and lifting (rare)
Patients will present with symptoms of spinal cord involvement with a hyperacute onset (less than 4 hours)
Although the “classic” presentation is anterior cord syndrome (flaccid paralysis, dissociated sensory loss (pinprick and temperature), preserved dorsal column function), patients may present with loss of all functions below the level of infarct due to spinal shock, confusing the clinical picture.
The most common level is T10
Rabinstein AA. Vascular myelopathies. Continuum (Minneap Minn). 2015;21(1 Spinal Cord Disorders):67-83.
Category: Critical Care
Improving Analgesia in Mechanically Ventilated ED Patients
Isenberg D, et al. Simple changes to emergency department workflow improve analgesia in mechanically ventilated patients. West J Emerg Med. 2018;19:668-74.
Keywords: PPI, Gi bleed (PubMed Search)
Continuous vs intermittent dosing of PPIs in bleeding peptic ulcer disease
There continues to be debate as to the optimal dose, frequency, and route of proton pump inhibitors (PPIs) in bleeding ulcers, especially prior to endoscopy. Multiple guidelines including from the American Journal of Gastroenterology continue to recommend continuous dosing of PPIs.1,2,3 However, multiple studies appear to show at least non-inferiority when compared with intermittent dosing of PPIs.
The most frequently cited study for non-inferiority is a meta-analysis of 13 randomized control trials by Sachar et al. which evaluated PPI use in patients presenting with upper GI bleeds who were endoscopically found to have a bleeding gastric or duodenal ulcer with high risk features (active bleeding, non-bleeding visible vessel, or adherent clot)4. There was non-inferiority of intermittent dosing in rebleeding, need for repeat endoscopy/surgery, RBC transfusions, and mortality with a non-statistically significant trend towards superiority of intermittent dosing.
However, the patients were only randomized to continuous vs intermittent dosing AFTER endoscopic treatment. In addition, the dosing regimen of intermittent dosing was quite variable.
Keywords: Asthma, chest xray (PubMed Search)
Chest xrays (CXRs) may lead to longer length of stay, increased cost, unnecessary radiation exposure, and inappropriate antibiotic use.
CXR in asthma are indicated for:
-severe persistent respiratory distress, room air saturations <91%
- focal findings (localized rales, crackles, decreased breath sounds with or without a documented fever > 38.3) not improving on >11 hours of standard asthma therapy
- concern for pneumomediastinum or pneumothorax
This study tried to use quality improvement measures to decrease the rate of chest xrays in children seen for asthma.
6680 children with billing codes for asthma had 1359 CXRs. Using a clinical practice guideline and then targeted intervention, the group was able to reduce CXR use from 29% to 16%. In subgroup analysis, the CXR use decreased from 21.3% to 12.5% for discharged patients and 53.5% to 31.1% for admitted patients.
The National Asthma Education and Prevention Program has created guidelines to help providers manage acute asthma exacerbations stating that CXRs should be reserved for patients suspected of having an alternate diagnosis such as pneumothorax, pneumomediastinum or congestive heart failure. This does not include the suspicion for associated pneumonia! A study of >14,000 patients with asthma showed that less than 2% also had pneumonia.
The interventions done in this study were:
An electronic asthma order set was created to include “CXR not routinely recommended”
Clinical practice guidelines were reviewed with residents, faculty, nursing, and respiratory therapy at regular intervals
Copies of the clinical practice guidelines were posted in a highly visualized area
CXRs removed from the default order set
Wheezing was removed as an indication for CXR
CXR in asthma are indicated for: severe persistent respiratory distress, room air saturations <91%, focal findings not improving on >11 hours of standard asthma therapy or concern for pneumomediastinum or pneumothorax
Watnick CS, Arnold DH, Latuska RL, O’Connor M, Johnson DP. Successful Chest Radiograph Reduction by Using Quality Improvement Methodology for Children with Asthma. Pediatrics. Published online July 11, 2018.
Keywords: Sulfonylureas, Octreotide (PubMed Search)
Sulfonylureas are commonly used oral hypoglycemic agents for type II diabetes. Agents on the market include glipizide (Glucotrol), glyburide (Micronase, Glynase, Dibeta) and glymepiride (Amaryl). These agents exert their effect by stimulation of insulin release from the pancreatic beta islet cells. Following overdose, hypoglycemia is usually seen within a few hours of ingestion and can be prolonged and profound. First line treatment for rapid correction of severe hypoglycemia is administration of an intravenous bolus of concentrated dextrose. However, use of dextrose infusion in attempt to maintain euglycemia is problematic as it can cause further release of insulin and rebound hypoglycemia. Octreotide ia a long acting synthetic somatostain analogue, blocks insulin secretion and has been shown to prevent recurrence of hypogylcemia better than placebo.
Comparison of Octreotide and standard therapy versus standard therapy alone for treatment of sulfonylurea-induced hypoglycemia, Fasano CJ, O’Malley, et al. Ann Emerg Med. 2008 Apr;51(4): 400-406.
Octreotide for the treatment of sulfonylurea poisoning. Glatstein M. et al. Clin Toxicol 2012;50:795-804.
Category: Critical Care
Keywords: noninvasive positive pressure ventilation, NIV, NIPPV, DNI, do-not-intubate, palliative care, end-of-life, respiratory distress (PubMed Search)
When a do-not-intubate (DNI) hospice patient arrives in the ED with respiratory distress, consideration of non-invasive positive pressure ventilation (NIPPV) could invoke either a “What other option do I have?” or “Why torture the patient and prolong the dying process?” sentiment.
But what’s the data?
A recently-published meta-analysis1 found that in DNI patients receiving NIPPV, there was a 56% survival rate to hospital discharge and 32% survival to 1-year.
Independent studies have demonstrated:
Keywords: Cervical spine, neuropraxia (PubMed Search)
Stingers and Burners
Also known as transient brachial plexus neuropraxia, “dead arm syndrome,” or brachial plexopathy. Symptoms such as pain, burning, and/or paresthesias in a single upper limb, lasting seconds to minutes.
Usually involves more than one dermatome
May be associated with weakness.
-Common in collision sports that involve tackling, such as football.
-Most common C-spine injury in American Football.
-More than 50% of college football players sustain a stinger each year
-Having 1 stinger increases the risk of having another 3 fold
Mechansims: C5, C6 (deltoid,biceps) most commonly involved
-Traction injury due to forcible lateral neck flexion away with downward displacement of arm
-Nerve root compression during combined neck extension and lateral neck flexion
-Direct trauma to the brachial plexus in the supraclavicular fossa
-Examine muscle strength in the deltoid, biceps, and infraspinatus muscles
-Check sensation and reflexes in upper extremities
-Check C-spine range of motion and perform Spurling’s Test
Consider MRI for symptoms lasting more than 24 hours, bilateral symptoms or for recurrent stingers
Return to play guidelines vary:
-No neurologic symptoms
-Can return to play in same game if symptoms resolve within 15 minutes and no prior stingers that season.
-If 2nd stinger in that season, do NOT return to play in the same game
-if 3rd stinger in a season, consider imaging before return to play and consider sitting out the remainder of the season.
Keywords: Pediatrics, Migraine, Abdominal Migraine, Headache (PubMed Search)
Abdominal pain in children can be just as frustrating as dizzy in the elderly. Your exam is targeted at quickly ruling out acute pathologies, but then what? The diagnosis is often functional gastrointestinal disorders, like the ever exciting constipation. Abdominal migraine (AM) is an additional entity to consider during your emergency department evaluation.
The following factors are often associated with AM:
- peak incidence at 7 years old
- paroxsymal, periumbilical abdominal pain lasting more than 1 hour
- family history of migraine
- episodes not otherwise explained by known pathology.
AM can be associated with headache, pallor, anorexia, photophobia, and fatigue. There are multiple theories on the pathogenesis, which can be found in the article cited below. If there is a known history, and the patient is presenting with an exacerbation, the treatment protocols for migraine headache may be employed with good success.
AM is increasingly recognized as a source of recurrent abdominal pain in children. If other organic pathologies can be ruled out, this may be an important diagnosis to consider so your patient can get the appropriate follow up and outpatient management.
Keywords: antimuscarinic/anticholinergic toxicity, reversal of delirium (PubMed Search)
From 1960s to 1970s, physostigmine was routinely administered as part of the "coma cocktail." Since the publication of two cases by Pentel (1980) that resulted in asystole after administration of physostigmine in TCA poisoned patient, its use has declined significantly.
However, physostigmine still possess limited but clinically useful role in the management of patients with antimuscarinic/anticholinergic induced delirium.
Recently, a prospective observational study was performed in the use of physostigmine when recommended by a regional poison center.
In 1 year study period, physostigmine was recommended by a regional poison center in 125 of 154 patients with suspected antimuscarinic/anticholinergic toxicity.
common exposures were
57 of 125 patients received physostigmine per treating team.
Of the remaining patients,
Adverse events (physostigmine group vs. non-physo group) - no statistically significant difference.
Physostigmine can safely control antimuscarinic/anticholinergic-induced delirium.
Boley SP et al. Physostimgine is superior to non-antidote therapy in the management of antimuscarinic delirium: a prospective study from a regional poison center. Clin Toxicol 2018 Jun 29:1-6. doi: 10.1080/15563650.2018.1485154. [Epub ahead of print]
Category: Critical Care
Legionella is an important cause of community-acquired pneumonia. It ranks among the three most common causes of severe CAP leading to ICU admission and carries a high mortality rate – up to 33%. Resulting from inhalation of aerosols containing Legionella species and subsequent lung infection, it is often associated with contaminated air conditioning systems, and other hot and cold water systems.
Recommended antibiotic regimens include a fluoroquinolone, either in monotherapy or combined with a macrolide (typically Levaquin +/- or Azithromycin).
A retrospective, observational study published in the Journal of Antimicrobial Chemotherapy in 2017 looked at 211 patients admitted to the ICU with confirmed severe legionella pneumonia treated with a fluoroquinolone vs a macrolide and monotherapy vs combination therapy. Combination therapy included fluoroquinolone + macrolide, fluoroquinolone + rifampicin, or macrolide + rifampicin.
Of these 211 cases, 146 (69%) developed ARDS and 54 (26%) died in the ICU. Mortality was lower in the fluoroquinolone-based group (21%) than in the non-fluoroquinolone based group (39%), and in the combination therapy group (20%) than in the monotherapy group (34%). In a multivariable analysis, fluoroquinolone-based therapy, but not combination therapy was associated with a reduced risk of mortality (HR 0.41).
Take Home Points:
-Remember, our usual blanket coverage with vanc + zosyn in the ED does not cover atypicals!
-Consider Levaquin instead of Azithro if there is clinical concern for Legionella PNA
-hyponatremia, abnormal LFTs may be clues in the appropriate context
Cecchini J, Tuffet S, Sonneville R, et al. Antimicrobial strategy for severe community-acquired legionnaires’ disease: a multicentre retrospective observational study. J Antimicrob Chemother. 2017;72(5):1502-1509. doi:10.1093/jac/dkx007.
Category: Pharmacology & Therapeutics
Keywords: Diabetes, DKA (PubMed Search)
Woodward RS, Flore MC, Machnicki G, Brennan DC. The long-term outcomes and costs of diabetes mellitus among renal transplant recipients: tacrolimus versus cyclosporine. Value Health. 2011;14(4):443-9.
Keywords: guidelines, protocols, safety, delirium (PubMed Search)
Based in part upon Geriatric Emergency Department Guidelines, the American College of Emergency Physicians has initiated a Geriatric Emergency Department Accreditation Program. Emergency departments (EDs) can be accredited at one of three levels- Gold (Level 1), Silver (Level 2) and Bronze (Level 3). There are various aspects upon which and EDs’ level is determined, including nurse and physician staffing and education, appropriate policies and protocols, quality improvement activities, outcome measures, equipment and the physical environment.
Keywords: capacity, dementia, altered mental status, medicolegal, ethics (PubMed Search)
Medical decision-making capacity refers to the patient’s ability to make informed decisions regarding their care, and emergency physicians are frequently required to assess whether a patient possess this capacity. Patients with acute or chronic neurological diseases (such as dementia) may lack this capacity, and this should be identified, especially in life-threatening situations. The patient must have the ability to:
communicate a consistent choice
understand (and express) the risks, benefits, alternatives and consequences
appreciate how the information applies to the particular situation
reason through the choices to make a decision
There are numerous tools that may help with this assessment, but none has been validated in the ED. Be careful of determining that the patient lacks capacity just because of the diagnosis they carry.
Capacity is a fluid concept; a patient may have the capacity to make simple decisions but not more complex ones. Capacity may also change over time
Psychiatry consultation to determine capacity is not obligatory but may be utilized for a second opinion.
Rodgers JJ, Kass JS. Assessment of Medical Decision-making Capacity in Patients With Dementia. Continuum 2018;24(3):920–925.
Category: Critical Care
Volume Responsiveness, Carotid Ultrasound, and the PLR
Gassner M, Killu K, Bauman Z, Coba V, Rosso K, Blyden D. Feasibility of common carotid artery point of care ultrasound in cardiac output measurements compared to invasive methods. Journal of Ultrasound. 2015;18(2):127-133.
ED visits for acute gout increased almost 27% between 2006 & 2014, a 26.8% increase
Presentation: Acute severe pain, swelling, redness, warmth.
Pain peaks between 12 to 24 hours and onset more likely at night
Quiet, calm period between flares vs other arthritic disorders
Signs of inflammation can extend beyond the joint
Normal to low serum urate values have been noted in 12 to 43% of patients with gout flares
Accurate time for assessment of serum urate is greater than 2 weeks after flare subsides
Most hyperuricemic individuals never experience a clinical event resulting from urate crystal deposition.
Gout flares may occasionally coexist with another type of joint disease (septic joint, psedugout),
A clinical decision rule has shown to be more accurate than clinical diagnosis (17 versus 36%)
*Male sex (2 points)
*Previous patient-reported arthritis flare (2 points)
*Onset within one day (0.5 points)
*Joint redness (1 point)
*First metatarsal phalangeal joint involvement (2.5 points)
*Hypertension or at least one cardiovascular disease (1.5 points)
*Serum urate level greater than 5.88 mg/dL (3.5 points)
Scoring for low (≤4 points), intermediate (>4 to <8 points), and high (≥8 points) probability of gout identified groups with a prevalence of gout of 2.2, 31.2, and 82.5 percent, respectively.
Consider supplementing your clinical decision with this in the future
Miathal A, Singh G. Emergency department visits for gout: a dramatic increase in the past decade. Oral presentation at the EULAR 2018 European Congress of Rheumatology in The Netherlands, June 13–16.
Kienhorst LB, et al. The validation of a diagnostic rule for gout without joint fluid analysis: a prospective study.Rheumatology (Oxford). 2015;54(4):609.
Becker, MA. Clinical manifestations and diagnosis of gout. Up to date. 2018
Keywords: DKA, cerebral edema, PECARN (PubMed Search)
Children with diabetic ketoacidosis (DKA) may have brain injuries ranging from mild to severe. The debate over the contribution from intravenous fluids towards poor neurologic outcomes has been ongoing for decades.
PECARN's large multicenter randomized, controlled trial examined the effects of the rate of administration and the sodium chloride content of intravenous fluids on neurologic outcomes in children with diabetic ketoacidosis may finally put the controversy to rest. There was no difference on significant neurologic outcomes based on the rate (fast vs slow) or concentration (0.9% vs 0.45%) of IV fluid administration.
Clinically apparent brain injury occurred in 12 of 1389 episodes (0.9%) of children in DKA.
Any change in the mental or neurological status of the patient should be concerning for life threatening edema and should be treated with mannitol 1g/kg IV bolus or hypertonic saline (3%) 5-10 mL/kg IV over 30 minutes.
Long, B; Koyfman, A. Emergency medicine myths: cerebral edema in pediatric diabetic ketoacidosis and intravenous fluids. J. Emerg. Med; 2017:53(2),212-221.