• Invasive candidal infections can carry a high mortality (up to 40%) and can hard to diagnose
• In the ICU it is important to know which patients are at risk for developing invasive candidal infections

Risk factors for invasive candidal infections

• Critical illness (long ICU stays)
• Abdominal surgery (anastomotic leaks, repeat laporatomies)
• Necrotizing pancreatitis
• Hematologic malignencies
• Solid organ transplant
• Solid organ tumors
• Neonates (low birth wt, preterm)
• Use of broad spectrum antibiotics
• Central lines/PICC lines
• TPN
• Hemodialysis
• Steroid use
• Candidal colinization (urine, sputum)  

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If there weren't enough reasons to avoid opioids, here is another: opioids don't work for low back pain (LBP).

Objective

A well-done, double-blind, randomized controlled trial from JAMA set out to compare functional outcomes and pain at 1 week and 3 months after an ED visit for acute LBP among patients randomized to a 10-day course of (1) naproxen + placebo; (2) naproxen + cyclobenzaprine; or (3) naproxen + oxycodone/acetaminophen.

Intervention

• Nontraumatic, nonradicular LBP of 2 weeks’ duration or less
• All patients were given 20 tablets of naproxen, 500 mg, to be taken twice a day.
  • They were randomized to receive either 60 tablets of placebo; cyclobenzaprine, 5 mg; or oxycodone, 5 mg/acetaminophen, 325 mg. Participants were instructed to take 1 or 2 of these tablets every 8 hours, as needed for LBP.
• Patients received a standardized 10-minute LBP educational session prior to discharge.

Outcome

Neither oxycodone/acetaminophen nor cyclobenzaprine improved pain or functional outcomes at 1 week compared to placebo, and more adverse effects were noted.

Application to Clinical Practice

Among patients with acute, nontraumatic, nonradicular LBP presenting to the ED, avoid adding opioids or cyclobenzaprine to the standard NSAID therapy.

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Designer drugs are structural or functional analogs of controlled substances produced to mimic pharmacological effects of the original compound while circumventing legal restrictions and detection on drug screens. Considered "legal highs" by the public, these highly potent drugs are produced in clandestine laboratories with no regulations for quality control or clinical testing for phamacological effects and thus present major threat to public health. Examples include synthetic hallucinogens (DOM: STP), opiates ( methylfentanyl:china white), stimulants (methamphetamine:crank, MDMA: ecstasy, cathinones:bath salts) and synthetic cannabinoids (spice).

The synthetic cannabinoids are the newest designer drugs and numerous cases of intoxication are being reported including some fatalties.Cannabinoids fall into 3 classes: endocannabinoids, phytocannabinoids, synthetic. Marijuana, the best known cannabinoid is plant derived and its psychoactive effects are mainly due to delta-9-tetrahydrocannabinol (THC) which binds with the endocannabinoid receptors CB1 and CB2 found throughout the central and peripheral nervous system and peripheral organs. The CB receptors interact with opiate receptors which is likely responsible for the analgesic effect.

Since 1984, the John Huffman research group at Clemenson University synthesized over 450 cannabinoid compounds for biomedical reseach known as "JWH compounds". These compounds hold great promise in the investigation of multiple diseases and development of new novel therapies. Over the last several years, these cannabinoid compounds began cropping up sprayed onto herbs marketed in colorful packets and sold on the internet, convienence stores, and head shops. Although clearly labeled as "not for human consumption" considered on the street as a legal alternative to marijuana.

Key Points:

• Common names: Spice, K2, Smoke, Skunk, Purple Haze, Scooby snax, Crazy Monkey.
• JWH 018 (4-5 fold greater affinity for CB receptor than THC), JWH 081,122, 210
• Exact composition of products unknown and ever changing to avoid legal restrictions.
• Cannabinoid dose can vary greatly between products and even within same package "hot spots" are found where the drug is more concentrated.
• Often shown to be contaminated with impurities like beta agonists clenbulterol
• No clinical human studies on effects or any routine detection assays available.
• Clinical effects can vary from commonly described anxiety agitation, tachycardia to sedation and somulence.

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- Anterior shoulder dislocations often require surgical management in young adults due to recurrence, but are less common in pediatric patients, particularly under age 10

- A study this year showed that 14-16 year olds are similar to 17-20 year olds in recurrence risk (around 38%- when non-operative management), and this is especially true of males.

- The recurrence rate is lower in the 10-13 age group, but there are also less dislocations in this group as well, making this group harder to assess

- Remember to consider both chronologic and bone age if you are deciding to refer a patient for outpatient surgery follow up, bone age is more accurate to determine healing and response to non-operative treatment

- Consider early referral for surgical management and counseling regarding recurrence risk in the 14-16 year age group after anterior shoulder dislocations

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Sickle Cell Disease (SCD) is a hemoglobinopathy that is considered a relatively rare disease in the United States, affecting about 90,000-100,000 individuals.

Globally, SCD affects millions, primarily in West and Central Africa.

Acute presentations of SCD include:

• Acute Pain (Sickle Cell or Vaso-occlusive) Crisis
  • Most common presentation in emergency departments
• Severe Anemia
  • Splenic sequestration crisis
  • Aplastic crisis
  • Hemolytic crisis
• Infections
  • Particularly from encapsulated organisms because of a damaged spleen (functional asplenia)
• Acute Chest Syndrome
  • From damaged lung tissues leading to hypoxia
  • A leading cause of death for patients SCD
• Stroke
• Priapism
• Other organ dysfunction including kidney failure and eye problems (retinopathy)

The bottom line: 

• Sickle Cell Disease is a serious, painful and potentially life threatening disease that can cause major damage to multiple organ systems.

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Pain Management in the Critically Ill Patient

• Pain is common, often underappreciated, and routinely undertreated in our critically ill patients.
• Poorly treated pain has been shown to adversely affect both short- and long-term outcomes.
• Key pearls when treating pain in the critically ill:
  • Vital signs should not be used in isolation to assess pain
  • Use a validated assessment tool to objectively quantify pain (i.e., Critical Care Pain Observation Tool)
  • An analgosedation strategy (analgesics before sedative medications) has been shown to decrease duration of mechanical ventilation and decrease ICU LOS
  • Opioids have no maximum or ceiling dose. The appropriate dose is that which controls pain with the fewest side effects.

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Question

Patient complains of facial and neck swelling, what's the diagnosis?

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Happy Halloween!! 

I hope you have had a safe and fun Halloween. Thank you to all the people that are staffing the EDs on a Saturday Night Halloween.

Prostate-Selective Alpha Antagonists have been tied to Falls and increased risk of fractues in elderly men.  These medications can lead to syncope and hypotension putting patients at increased risk of falls. A recent canadian study showed that at 90 days of use; individuals on alpha antagonists were at increased risk of hospital visits for falls (1.45% vs. 1.28%) or fractures (0.48% vs. 0.41%). There was also an increased risk of  head trauma.

Please warn patients that are on these medications of the risks, so that injuries can be minimized. They should take specific care when changing postural positions, and report episodes of lightheadedness to their PCPs.

The article can be found at http://www.bmj.com/content/351/bmj.h5398

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A traditional ED practice has been to combine promethazine as an anxiolytic adjunct to morphine for patients with musculoskeletal pain (eg back pain).

However, when compared to morphine alone, this combination does not lead to greater analgesia or decrease anxiety. It does however prolong ED length of stay.

This use of this "pain cocktail" is not recommended

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Fever is the most common presenting symptoms to pediatric emergency departments 10-20%

• Urine bag 46%
• Clean catch 14-26%
• Catheterization 12-14%
• Suprapubic aspiration 1-9%

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There have been a variety of case reports that have been describing the effects of lipid emulsion therapy on severe hemodynamic overdoses. As time has gone on, we have realized that this therapy is not for all severe overdoses. The type of medication and its pharmacokinetic properties factor into the decision. There is minimal evidence and no ideal randomized control trials that will tell us what the right answer is but take beta-blockers for instance:

Atenolol - in overdose, consider hemodialysis, very effectively removed by HD [1]

Propranolol - very lipophilic and one of the few beta-blockers that can cause widened QRS, seizures as well as the prototypical hypotension and bradycardia.

Because of its lipophilicity, ability to cross the blood brain barrier and ability to cause lethal dysrrthmias, lipid emulsion therapy has been effective in reversing the clinically severe effects of a propranolol overdose. [2]

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The World Health Organization (WHO) has just released a report on the current status of road traffic safety globally.

• 1.25 million people die each year from road traffic crashes
• 90% of road traffic deaths occur in low- and middle- income countries
  • Only 54% of the world vehicles are in these countries
• Countries in Africa have the highest death rates per capita
• Vulneable groups include:
  • Motorcyclists (23% of global deaths)
  • Pedestrians (22% of global deaths)
  • Cyclists (4% of global deaths)

From a postive perspective, road traffic deaths are stabilzing even though the number of motor vehicles are rapidly increasing.

The bottom line- injuries are preventable.  Continued policy efforts, laws with enforncement, can save lives. Specific life saving legislation includes:

• seat belt laws that apply to all occupants
• maximum speed, such as urban speed limits of 50 Km/h (31 mph)
• child restraint, based upon age, height or weight
• helmet laws that apply to all drivers, passengers and road types
• drink-driving laws with specific blood alcohol concentrations (e.g.: 0.05 g/dl or less)

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There is more than the standard preparations of plasma, platelets, and PRBCs in the blood bank. Certain patients will require these specialized preparations when a transfusion is required. Here are three to know:

• Leukoreduced (PRBCs are run through a filter to reduce the total WBC burden)
  • Most of the blood in USA is leukoreduced
  • Should be requested for pre-transplant patients and patients who previously experienced febrile non-hemolytic reactions
• Irradiated PRBCs (radiation incapacitates donor WBCs)
  • Irradiation prevents the fatal transfusion-associated graft versus host disease, which occurs in patients who are severely immunosuppressed or who are closely related to the blood product donors.
• Washed RBCs/platelets (washing removes plasma, cell fragments and excess potassium)
  • Washed cells are used for neonates/pediatric patients due to sensitivity to potassium in normal products; in adults, it is used for patients with prior allergic reactions to blood products or IgA deficiency

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Question

8 year-old female presents with nausea, vomiting, double-vision and inability to move her left eye upwards after being kicked in the face at school. What's the diagnosis?

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Our suspicion of significant abdominal injury increases when there is bruising across the abdomen in adults after a motor vehicle collision, but what about in children? A PECRAN analysis may have provided us with the answer.

Of 3740 pediatric patients after motor vehicle collision, 16% had a seat belt sign. Seat belt sign was defined as a continuous area of erythema, ecchymosis or abrasion across the abdomen due to the seat belt. 1864 children had CT scans of the abdomen. Intra-abdominal injuries (IAI) were more common in those children with seat belt sign than those without (19% versus 12%). Those with seat belt sign had a greater risk of hallow viscous or mesenteric injuries. There was no increased risk of solid organ injury. 33% of patients with seat belt sign did not have complaints of abdominal pain or tenderness on initial exam (with a GCS of 14 or 15); 2% of these patients underwent operative intervention for their injuries.

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Toxicity due to body packing and body stuffing can be a significant concern due to unknown quantity and/or substance that was ingested.

• Body stuffers usually ingest small quantities of poorly wrapped illicit substance (intended for sale) to evade law enforcement.
• Body packer ingests large quantities of well-packaged illicit substance for trafficking purpose. Rupture of these packets can potentially result in fatal toxicity.

A recent prospective observational case series compared the utility of CT abdomen/pelvis with and without PO contrast in identifying the ingested packets.

The gold standard comparison: surgical removal or expulsion of packets.

All patients received CT abd/pelvis with and without PO contrast.

A. Body stuffers (n = 24)

CT w/ PO contrast:

• Positive: 7 (sensitivity 29.2%)

• Negative: 17  

CT w/o PO contrast:

• Positive: 9 (sensitivity 36.5%)

• Negative: 15

All 24 patients passed ingested packets

B. Body packers (n= 11)

CT w/ PO contrast

• Positive: 6 (sensitivity 60%)
• Negative: 5

CT w/p PO contrast

• Positive: 7 (sensitivity 70%)
• Negative: 3

10 patients expulsed packets; one patient did not have any packets.

Conclusion

• CT without PO contrast was better at identifying the ingested packets in both body stuffers and packers.

Bottom line:

• CT abdomen/pelvis has limited clinical utility in identifying the packets (presence) among body stuffers. If symptomatic, appropriate supportive care should be initiated
• Among packers who may experience life-threatening toxicity from the leakage/rupture of the packets, CT may be helpful to confirm the presence of packets and to follow the progress of expulsion of packets.
• Caution should be exercised as CT did not identify packets (body stuffer or packers) in all patients in this case series.

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Last month we discussed symptoms of serotonin syndrome and its diagnosis by the Hunter Criteria. Let's move on to what causes serotonin syndrome.

Serotonin Syndrome - What Causes It?

• Serotonin syndrome is not an idiopathic drug reaction, but the result of excess serotonin in the nervous system.
• It is classically associated with adminstration of two serotonergic agents, but it can occur after initiation of a single agent or increasing the dose of a serotonergic agent in individuals who are particularly sensitive to serotonin.
• Although selective serotonin reuptake inhibitors (SSRIs) are most commonly implicated, there are other medications encountered in the Emergency Department that can also play a role in serotonin syndrome.

• There are also reports of serotonin syndrome occuring with methadone, trazodone, and metaxalone (Skelaxin).
• Serotonin syndrome is often under-recognized if the symptoms are not severe.  Thus a thorough medication history is important in its purely clinical diagnosis.

** Stay tuned for the conclusion on management of serotonin syndrome **

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• A recent trial looked at the three common sites for central venous catheters in 3471 catheter insertions
• The primary outcome was a composite of catheter-related bloodstream infection and DVT
• The femoral line group had a higher risk of DVT and infections although the risk from both is still very low
• Pneumothorax occurred in 1.5% of subclavian lines and 0.5% of jugular lines
• Subclavian lines are thought to have lower infection rates due to a longer subcutaneous courses before entry. They also have the lowest bacterial bioburden and tend to be protected against disruption

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Question

5 year-old boy who presents with sudden onset hoarse voice, and drooling without a fever. 

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