This really interesting study suggests that the classic site of CPR “in the middle of the chest” may actually not be the ideal place to perform CPR. Previous imaging studies demonstrate that the ventricles are primarily beneath the lower third of the sternum and that standard placement of CPR compressions may deform the aortic valve, blocking the LVOT, and theoretically limiting perfusion of the coronaries and brain.
This study compared a standard CPR group with those undergoing TEE-guided chest compressions to avoid aortic valve compression. Those in the non-AV compression group had significantly increased likelihood of ROSC, survival to ICU, and higher femoral arterial diastolic pressures. However, there was no difference in long-term outcomes or end-tidal CO2.
Summary: Avoiding AV compression during CPR significantly improved the chance at ROSC in adult OHCA, but this small observational study did not show any difference in long term outcomes when compared to standard practice. Lowering the point of chest compressions in CPR to the lower third of the sternum may be beneficial.
Do you have a patient with a finger injury or infection, or possibly a retained foreign body?
Try placing the hand in a water bath and use a linear ultrasound probe for evaluation. If there is an open wound, use a sterile ultrasound probe cover.
With ultrasound guidance, you can observe dynamic finger movements and identify areas that may require abscess drainage.
In this Scandinavian study looking at 2,362 head injury patients on oral anticoagulants, the authors found only 5 cases of delayed hemorrhage and none of the five underwent neurosurgery. The authors concluded:
“In patients with head trauma, on oral anticoagulation, the incidence of clinically relevant delayed intracranial hemorrhage was found to be less than one in a thousand, with detection occurring four days or later after initial presentation.”
It would appear based on this study and others that it is safe to discharge these patients with a normal head CT and giving strict return precautions for headache, nausea, vomiting or other changes.
Histamine is present in mosquito saliva contributing to itch with bites, however, certain populations – including children – can experience an exaggerated reaction. Skeeter syndrome is a large, localized inflammatory reaction secondary to a mosquito bite that presents with warmth, swelling, and itching. There can occasionally be associated lymphadenopathy and fever as well. The rapid onset is what best differentiates it from cellulitis. Treatment is primarily symptomatic in nature, focused on relieving itch, with antihistamines and topical therapy. There may also be a role for prophylactic antihistamine usage at times when mosquito bites will be unavoidable in a patient known to have developed Skeeter syndrome previously. Other patients who may be affected include those with immunologic and autoimmune phenomena, those with underlying atopy, outdoor workers with frequent exposure, and those with new exposure to indigenous mosquitos.
Take Home: Consider insect (mosquito bite) when evaluating for cellulitis/infection in pediatric patients, with impressive skin findings but otherwise unremarkable exams. They present with rapid onset and itching instead of pain. This can be especially prominent in periorbital and auricular presentations.
Title: Basics of Sleep Physiology and Architecture
By: Youssef Annous, MD
Sleep is integral for physical and mental health and performance. Sleep is extremely well conserved among species. All mammals need sleep to survive.1 A single sleep cycle typically lasts anywhere between 90 and 120 minutes and is broken down into two phases2:
Non-Rapid Eye Movement sleep
Stage 1 (Light Sleep)
This is the lightest form of sleep and the easiest to wake up from. During this stage, it is normal to experience muscle twitching and the sensation of drifting in and out of consciousness. This stage lasts approximately 5 minutes in the beginning of sleep and comprises around 5% of total sleep duration.2
Stage 2 (Light Sleep)
During this stage, you are likely to begin experiencing decrease in body temperature, heart rate (HR), blood pressure (BP) and respiratory rate (RR). Electroencephalography (EEG) during this phase of sleep would show sleep spindles and K complexes.2 These findings have been linked to memory consolidation.3
Stage 3 (Deep Sleep)
This is the deepest stage of sleep. During this phase, body temperature, HR, BP, and RR are at their lowest. This is the most restorative stage of sleep. It is essential for immune health, cardiovascular health, tissue repair, bone growth, and muscle recovery.2 It is also when growth hormone (GH) is at its highest. Physiological (e.g. illness) or psychological (e.g. anxiety) stressors can negatively impact this stage. We experience less deep sleep as we age.4
Rapid Eye Movement (REM) sleep
This stage of sleep is characterized by rapid eye movement, abundance of dreaming and heightened brain activity. During REM, there is total body paralysis with exception of ocular and respiratory muscles. It is theorized that your body is paralyzed during this stage to protect you from dream enactment. You experience more REM the longer you sleep. REM has been shown to be essential for memory consolidation, cognitive function, mood regulation and for coping with stress. This stage is particularly compromised by sedatives including but not limited to alcohol, benzodiazepines, and tetrahydro-cannabinoid (THC). Several studies in animals and humans showed that even modest REM sleep deprivation can result in increased mortality. 2,5,6
All sleep stages are extremely essential. Be careful of self-medicating with sleep aids such benzodiazepines or alcohol as this can be detrimental for your health. In later UMEM pearls, we will discuss protocols, supplements and behavioral ways to improve each stage of sleep for better mental and physical health.
This Delphi study and companion editorial highlight current thought on frailty screen in emergency department patients. Key takeaways are:
Emergency departments should be instituting procedures that incorporate screening older patients for frailty. These references are a good starting point.
On exam, assess for facial instability and airway patency. CT scan is the imaging of choice. The higher the number, the more complex the fracture, the more unstable and the more difficult the airway managment will be. Look for open lacerations or blood in the sinuses and treat with antibiotics if these are found. Consult ENT or plastics urgently for further management.
The reference is a nice review of these fractures
A recent study in Annals of EM investigated the use of topical Diclofenac in the treatment of lower back pain.
Small studies have shown topical NSAIDs to be effective for single joint OA and tendinopathies.
Currently, NSAIDs are first-line treatment for ED patients with acute low back pain.
Theoretically, topical NSAIDs deliver medications directly to the injured tissue while minimizing systemic side effects.
-Topical NSAIDs provide similar concentrations of the drugs in muscle tissue but much lower plasma concentrations than oral formulations
Design: Randomized, double-blind, placebo-controlled trial.
ED patients aged 18 to 69 years with non-radicular, non-traumatic acute lower back pain.
Screened 3,281 and enrolled 198.
Study groups:
Patients received 2 days of meds. Follow up by phone at 2 and 7 days.
Investigators used the RMDQ score to measures pain and functional impairment.
Results: At the 2 day follow-up, all 3 groups showed an improvement in the mean RMDQ score compared to baseline as expected.
Participants had a mean RMDQ improvement of 10.1 in the ibuprofen group, 6.4 in the diclofenac gel group, and 8.7 in the ibuprofen + diclofenac gel group.
At the 7-day follow-up, participants had a mean RMDQ change compared to baseline of 12.2 in the ibuprofen group, 9.5 in the diclofenac group, and 10.7 in the ibuprofen + diclofenac gel group.
Conclusion: This study does not support the use of topical diclofenac among patients who can otherwise tolerate oral ibuprofen.
Because the study did not compare placebo gel to topical Diclofenac, we cannot infer whether topical medication is helpful for treatment in acute lower back pain in those patients who may not be able to take NSAIDs.
This very small study looked at the utility of using IV contrast media to enhance abdominal sonography in identifying injuries in blunt abdominal trauma patients. The comparison was CT scanning of the abdomen to identify injuries. The study concluded:
“With the addition of contrast and careful inspection of solid organs, abdominal sonography with contrast performed by the emergency physician improves the ability to rule out traumatic findings on abdominal CT. CEUS performed by emergency physicians may miss injuries, especially in the absence of free fluid, in cases of low-grade injuries, simultaneous injuries, or poor-quality examinations.”
To me, this is a limited study and the technique is not ready for wide spread use but further study is warranted.
There is a growing trend toward the development of specialty-specific emergency services, such as Geriatric or Oncologic EDs.
Will this trend continue? Is the segmentation of emergency care in our future? The author of this article opines that the answer depends on future outcomes research in this area.
Historically, guideline recommendations have been to use a transfusion threshold of hemoglobin < 7 g/dL for patients unless they are a) undergoing orthopedic surgery or b) have cardiovascular disease (CVD).
Applefeld et al conducted a meta-analysis in 2018 which suggested that restrictive (i.e. lower hemoglobin trigger, typically 7-8) transfusion targets lead to worse outcomes in CVD patients than liberal (i.e. higher hemoglobin trigger, typically 9-10) targets, and those authors have updated this analysis to include data from newer trials. Interestingly, the conclusion remains similar: that when you look at the larger studies on restrictive vs liberal transfusion targets, CVD plays an important role, as patients with CVD tend to do better with liberal targets, and patients without CVD tend to do better with restrictive targets. Of note, CVD is variably defined in these studies, and sometimes limited only to active Acute Coronary Syndromes, and other times refers to all patients with acute or chronic CVD. However, according to their analysis, the aggregated data suggests that we should continue having higher transfusion targets in patients with CVD, and perhaps even more in the 9-10 range, as opposed to the goals of 7 or 8 which are common.
Bottom Line: We will likely continue to see different transfusion targets recommended for patients with cardiovascular disease (CVD), and may even see guideline and blood bank recommendations raise the target for these patients more into the 9-10 range, or expand this group to include chronic CVD. This would mean a substantial increase in recommended RBC transfusions, and as emergency physicians it is important for us to monitor these recommendations, especially since transfusions are not harmless and raising hemoglobin thresholds could lead to complications that are difficult to measure in the literature.
Starting a study? Frame your research question in the PICO format:
Patients (consider severity of presentation, setting, demographics)
Intervention (either something you propose or something in use)
Comparison (another group, the same group without intervention, or a benchmark)
Outcome (a measurement)
This classic format has been used to evaluate studies, as in Journal Club (by our esteemed Dr. Wilkerson), as a literature search tool, or by the Cochrane review.
Starting with a PICO research question can help you narrow your focus and maintain it.
In this podcast, the concept of vasopressor use in hemorrhagic shock is discussed. Key take away points:
This was a cross sectional study examining insurance data to determine if there is seasonality related to ED visits and psychiatric hospitalizations related to suicidality.
Suicidality includes both suicidal ideation and suicide attempts (but not suicide). One survey showed that up to 12% of US adolescents reported serious thoughts of suicide. This study included 73,123 patients where 19.4% were direct inpatient admissions and 80.6% were ED visits, 44% of whom were subsequently admitted.
Metrics for suicidality in 10-18 year olds peaked in April and October with a nadir in June. Incidentally, in the Spring of 2020 when US schools closed due to COVID, there was a decrease in both ED visits and hospitalizations with April and May having the lowest rates across the study period.
School is believed to increase stress with risk factors such as bullying and peer pressure, academic and extracurricular stressors and poor sleep hygiene.
Bottom line: There has been an increase in adolescent suicidality over the recent years, many of whom present to the ED for evaluation. More mental health resources are needed, especially during the school year.
Maternal morbidity continues to increase in the US with a mortality rate in 2021 of 39.2 deaths/100,000 live births. There has been an intense focus on training and quality improvement within hospitals, but not much has changed in the prehospital education arena. This study aimed to quantify the complications encountered by EMS clinicians.
In the 2018-2019 EMS dataset used, there were a total of 56,735,977 EMS activations which included 8641 out of hospital deliveries, 1712 documented delivery complications and 5749 records of newborns.
1% of the out of hospital deliveries had a documented complication for the mother. Of these complications, 94% were for hemorrhage, 6% for abnormal presentation, 0.2% for shoulder dystocia, and 0.4% for nuchal cord.
Few patients had medications given, including 0.4% receiving oxytocin. no patients received prehospital blood transfusion or TXA. Of note, in the years since this data was obtained, TXA and whole blood have started to appear on more medic units, but it is still not necessarily commonplace.
Bottom line: While still rare, prehospital delivery does occur and EMS should be prepared for any possible complications. Medical directors should look at their jurisdictional/state protocols to see if oxytocin/TXA or whole blood should be included (if not already available). EMS clinicians should be educated on up to date management of OB emergencies.
This retrospective study looked at patients diagnosed with urinary tract infections receiving an IV dose of antibiotics prior to discharge and compared ED length of stay and return visit rate. They found:
“Parenteral antibiotic administration in the ED was associated with a 60-minute increase in ED LOS compared with those who received an oral antibiotic (P < 0.001) and a 30-minute increase in ED LOS compared with no antibiotic (P < 0.001). No differences were observed in revisits to the ED at 72 hours”
Appears no benefit to the practice of IV antibiotics prior to discharge in UTI patients.
Hemodynamic instability in trauma patients is most often associated with hemorrhagic shock, however, there is an entity known as brain injury associated shock (BIAS). BIAS is thought to be associated with catecholamine surges secondary to brain injury. BIAS is found in both isolated head injury pts as well as multi-trauma patients. Studies have identified BIAS in 13% of adult trauma patients and up to 40% of pediatric major trauma patients.
We know hypotension in brain injury worsens outcome. We should assume hemorrhagic etiology until we prove otherwise. Once we suspect BIAS and have excluded hemorrhagic etiology our strategy should switch to blood pressure support using non-blood product management.
Concussion Visits to the Emergency Department
In a study looking at concussion discharge instructions in the ED:
A 2020 study looked at patients aged 6-18 years diagnosed with concussion on either first or subsequent ED visit.
Those patients with delayed diagnosis required more medical visits during recovery, had a significantly longer time to symptom resolution (21 vs. 11 days), and had a higher likelihood of having persistent concussion symptoms.
Take home: Consider printed concussion discharge instructions in the appropriate ED patients as this has downstream benefits for health and recovery.
Intranasal medications are an increasingly popular option for pediatric patients, particularly for analgesia and anxiolysis, with an increasing number of medications being used via the intranasal route of administration.
Fentanyl has been shown in prior studies to be a safe and effective pain management strategy for children, but is likely under utilized. In sickle cell patients, studies have shown that time to analgesia may improve outcomes including hospitalization.
In 2023, Rees et al. showed that in the sickle cell patient population IN fentanyl can be a very effective tool for patient's experiencing a Vaso-occlusive episode (VOE). This study looked at 400 children with a mean age of 14.6 years. Of these 19% received IN fentanyl.
Ultimately, the IN fentanyl patient population had a shorter time to initial administration of analgesia and a lower chance of admission to the hospital.
Notably, this was not a randomized study, so there is limitations in assessment of the causality of the lower discharge rates. However this is a tool that could likely be used more regularly in the pediatric sickle cell patient population to allow for more rapid pain management in the emergency department.
