Ketamine is gaining traction as a prehospital option for managing severe agitation or excited delirium syndrome. Previous reports have mostly been case series, but a new prospective study adds some important information that may help delineate ketamine's role in this setting. [1] The study and an accompanying commentary are both open access. [2]
What They Did
Open-label before-and-after prospective comparison of haloperidol (10 mg IM) versus ketamine (5 mg/kg IM) for the treatment of acute undifferentiated agitation.
What They Found
Appliation to Clinical Practice
Gadolinium - To Use or Not Use?
| Non-Contrast MRA/MRV | Contrast-Enhanced MRA/MRV | |
| How Does It Work? | * Time-of-flight (TOF) is a commonly used sequence * Relies on flow of blood into imaging plane * Difference between signal of blood and suppressed background tissue | * Similar to CT angiography/venography * Higher intravascular signal purely from gadolinium-based contrast, not dependent on flow
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| Pros | * Does not require contrast
| * Generally better image quality * Shorter acquisition time |
| Cons | * Slow, turbulent, or retrograde flow may result in signal loss * Over-estimates stenosis * Longer acquisition time | * RIsks associated with contrast use * Timing of image acquisition important |
| Applications | * Patients with allergy to gadolinium, renal dysfunction, pregnancy * Evaluation of intracranial vessels and cerebral venous system | * Evaluation of stenoses and occlusions of the neck vessels and their origins at the aortic arch
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In settings where community-acquired MRSA is prevalent, which antibiotic is best for uncomplicated wound infections?
New Study
What They Found
Application to Clinical Practice
Bupropion (Wellbutrin, Zyban) is one of the most frequently prescribed antidepressants and smoking cessation agents. A lesser incidence of undesirable side effects such as weight gain and sexual dysfunction when compared to other antidepressants lends to its popularity. Bupropion's mechanism of action is only partially understood but it is known to be a norepinephine dopamine reuptake inhibitor and anticholinergic receptor blocker at certain nicotinic receptors. Bupropion has a monocyclic structure similar to amphetamines. Seizures are a major concern in overdose. When first released, Bupropion was initially withdrawn from the market due to its narrow therapeutic window with seizures occurring at doses as low as 450 mg.
As we head into the summer travel season, it is important to know what potential dangers lurk out there for the unwary traveler. While injuries are usually the primary cause for death and disability for Americans abroad, what about other diseases?
The Centers for Disease Control and Prevention (CDC) has a webpage with travel health notices.
They are three types of notices:
Currently, there are a number of Level 1 watches and Level 2 alerts for different countries, but no Level 3 warnings. Many of the Level 2 alerts relate to Zika virus, but there are others for MERS, Yellow Fever and Polio.
To see more, go to: http://wwwnc.cdc.gov/travel/notices
Radiographs of the sacrum and coccyx in the emergency department (ED) have no quantifiable clinical impact, according to a study published in the American Journal of Roentgenology.
Researchers from Emory University Midtown Hospital and Morehouse School of Medicine in Atlanta, GA, sought to determine the yield and clinical impact of sacrum and coccyx radiographs performed in the ED.
Sacrum and coccyx X-rays performed on 687 consecutive patients over a six-year period in level-1 and level-2 trauma centers (4 total hospitals). The patients’ mean age was 48.1, 61.6% were women. The images were categorized as positive for acute fracture or dislocation, negative, or other.
The researchers then analyzed:
• Follow-up advanced imaging in the same ED visit
• Follow-up advanced imaging within 30 days
• New analgesic prescriptions
• Clinic follow-up
• Surgical intervention within 60 days
The researchers found positive results in 58 of the 687 patients, a positivity rate of 8.4%.
None of the 58 positive cases had surgical intervention.
There was no significant association between sacrum and coccyx radiograph positivity and analgesic prescription or clinical follow-up among the patients evaluated at the level-1 trauma centers.
However at the level-2 trauma centers, 34 (97.1%) of 35 patients with positive sacrum and coccyx radiographs received analgesic prescriptions or clinical referrals. Negative cases were at 82.9%.
Of all cases, 39 patients (5.7%) underwent advanced imaging in the same ED visit and 29 patients (4.3%) underwent imaging within 30 days.
“Sacrum and coccyx radiography results had no significant correlation with advanced imaging in the same ED visit,” the authors wrote. “There was no significant difference in 30-day advanced imaging at the level-1 trauma centers, but there was at the level-2 trauma centers.”
The researchers concluded that routine sacrum and coccyx radiography should not be part of ED practice and that patients should be treated conservatively based on clinical parameters.
Short Answer: No
Classically, some therapies for headaches are thought to be effective in only certain classifications of headaches, such as triptans in migraines, or oxygen in cluster headaches. This is not necessarily true.
Triptans have been successfully used in cluster headaches, as found in the 2013 Cochrane review.1
More recently, "high-flow" oxygen (referring to 12 L/min of oxygen, delivered through a facemask) has been studied in migraine headaches, with promising results. When compared with placebo (air), oxygen used for 15 minutes was more effective in pain relief and improving visual symptom, with no significant adverse events. 2
American Thoracic Society (ATS) Conference Highlights
The ATS conference was last week in San Francisco and a few cool articles were presented. They are briefly summarized below:
1. Using a helmet vs face mask for ARDS: Non-invasive ventilation is not ideal for ARDS for a variety of reasons. At the same time, endotracheal intubation and ventilation carries some risks as well. Could a new design of a "helmet" device make a difference? This one center study from the Univ of Chicago suggests that it would: decreased rate of intubation, increase in ventilator free days, and decrease in 90 day mortality. http://jama.jamanetwork.com/article.aspx?articleid=2522693
2. Can aspirin prevent the development of ARDS in at risk patients in the emergency department? Unfortunately, it does not appear to help. http://jama.jamanetwork.com/article.aspx?articleid=2522739
3. Should you start renal-replacement therapy (HD, CRRT etc) in critically ill patients with AKI sooner or later? Seems to have no difference and may actually lead to patients not needing any dialysis. Really a great read if you have time. http://www.nejm.org/doi/full/10.1056/NEJMoa1603017?query=OF&
4. Should I extubate at night? Lastly, probably don’t extubate at night if you can avoid it. Or just be cautious. http://www.atsjournals.org/doi/abs/10.1164/ajrccmconference.2016.193.1_MeetingAbstracts.A6150
The American Academy of Pediatrics has developed a new set of clinical practice guidelines to help better manage and think about patients who have experienced an ALTE (Apparent Life Threatening Event). The term BRUE (Brief Resolved Unexplained Event) will replace ALTE.
BRUE is defined as an event in a child younger than 1 year where the observer reports a sudden, brief and now resolved episode of one or more of: cyanosis or pallor; absent, decreased or irregular breathing, marked change in tone or altered level of responsiveness. A BRUE can be diagnosed after a history and physical exam that reveal no explanation.
BRUE can be classified as low risk or high risk. Those that can be categorized as low risk do not require the extensive inpatient evaluation that has often occurred with ALTE.
LOW risk BRUE:
Age > 60 days
Gestational age at least 32 weeks and postconceptual age of at least 45 weeks
First BRUE
Duration < 1 minute
No CPR required by a trained medical provider
No concerning historical features (outlined in the article)
No concerning physical exam findings (outlined in the article)
Recommendations for low risk BRUE:
-SHOULD: Educate, shared decision making, ensure follow up and offer resources for CPR training
-May: Obtain pertussis and 12 lead; briefly monitor patients with continuous pulse oximetry and serial observations
-SHOULD NOT: Obtain WBC, blood culture, CSF studies, BMP, ammonia, blood gas, amino acids, acylcarnitine, CXR, echocardiogram, EEG, initiate home cardiorespiratory monitoring, prescribe acid suppression or anti-epileptic drugs
-NEED NOT: obtain viral respiratory tests, urinalysis, glucose, serum bicarbonate, hemoglobin or neuroimaging, admit to the hospital solely for cardiorespiratory monitoring
*When looking at the evidence strength behind these recommendations, the only one that had a strong level was that you should not obtain WBC, blood culture or CSF
The classification of blast injuries was first described by Zuckerman in 1941 and is still widely used today. This system organizes injuries by the mechanism through which they are sustained and classifies them as primary, secondary, tertiary and quaternary. These injuries may occur in isolation or in combination with each other.
| Category | Mechanism | Typical Injuries |
| Primary | Caused by blast wave of overpressure | Tympanic membrane rupture, blast lung, intestinal hemorrhage and rupture |
| Secondary | Caused by flying debris and shrapnel | Blunt and penetrating traumatic injuries
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| Tertiary | Due to individual being thrown by blast | Blunt and penetrating traumatic injuries
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| Quaternary | Thermal, toxic, and asphyxiant effects | Thermal burns, chemical burns, exposure to toxins, asphyxiation
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The term quinary blast injury has also been used to describe delayed effects of explosions, such as infections, radiation exposure, and other toxic exposures.
Author: R. Gentry Wilkerson
Situations Where ECMO Will Likely Fail
https://www.youtube.com/watch?v=sCFOObsx_W4
What is their risk of MI???
Anger outbursts are bad for your heart. Out of 300 patients with an acute MI, just over 2% reported losing their temper within 2 hours of the event. A review of nine studies of rage and cardiovascular events all found an increase in cardiovascular events in the 2 hours preceding an anger outburst. Examples included arguments at home, at work or by road rage. Compared with their usual anger levels, the relative risk of heart attack from a fit of rage was 8.5.
What about those of us who are just fanatics, I mean fans....A recent study of World Cup soccer found that the intense strain and excitement of viewing a dramatic soccer match more than doubles the risk of acute heart attack, particularly in men with known coronary heart disease. This was regardless of the outcome of the match!
Patients with chronic digoxin toxicity generally have multiple co-morbidities such as renal failure, dehydration, and cardiac failure. Sick patients with chronically high digoxin levels may have more than just digoxin toxicity as the cause of illness.
A New Study
Prospective observational study with the primary objective to investigate changes in free digoxin concentrations and clinical effects on heart rate and potassium concentrations in chronic digoxin poisoning when digoxin immune Fab are given.
What They Found
One to two vials of digoxin immune Fab initially bound all free digoxin confirming Fab efficacy. However, this was associated with only a moderate improvement in HR (49 to 57 bpm) and potassium (5.3 to 5.0 mmol/L).
Application to Clinical Practice
Want to learn more about how to read a brain MRI? Here are the basics:
Stay tuned for more pearls in this series on brain MRI!
Zika virus has received significant media attention in the US due to its recent link with teratogenicity. But Zika is also associated with critical and life-threatening complications, including death. Differentiating it from other Flavivirus diseases such as Dengue or Chikungunya can be challenging.
Diagnosis
Complications
Ketamine is often thought to be the induction agent least associated with hypotension in the peri-intubation period. However, reports of hypotension following ketamine do exist, including 2 cases of cardiac arrest. [1] There are limited objective means to predict which patients may have an adverse hemodynamic response.
New Study
A new prospective observational study followed 112 patients in the prehospital setting who received ketamine for rapid sequence intubation. 81 had a low shock index [< 0.9], 31 had a high shock index. [2]
Shock index = HR / SBP
What They Found
Patients with a high shock index were more likely to experience hypotension (SBP < 90 mm Hg) in the peri-intubation period compared to those with a low shock index (26% vs 2%).
Application to Clinical Practice
Why are selfie deaths on the rise?
People travel everywhere now with their camera equipped smart phones. Capturing a selfie while travelling is very common. This leads to more distracted people and lack of situational-awareness.
Where and how do these deaths occur?
Selfies taken from a height, on a bridge, near motorized traffic, during thunderstorms, at sporting events and near wild animals
Other information:
Submitted by Dr. Laura Diegelmann
Neonatal jaundice- Incidence ~85% of term newborns
Bili levels are EXPECTED to rise during first 5 days of life
Be aware of CONJUGATED hyperbilirubinemias (biliary atresia, infection)
Majority of cases due to increase in unconjugated (indirect) bilirubin 2/2 residual fHgb breakdown and insufficient capacity of hepatic conjugation
Severe hyperbilirubinemia (Tbili >20mg/dL) <2% of term infants
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Acute bilirubin encephalopathy(ABE)- Hypertonia, arching, opisthotonos, fever, high pitched cry
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Kernicterus (5% of ABE)-CP, MR, auditory dysfunction, upward gaze palsy
When to refer for phototherapy/exchange transfusion
