20% of unexplained falls in the elderly can be attributed to an arrhythmia.

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Alpha-blockers (tamsulosin, alfuzosin, doxazosin, and terazosin) are antagonists of alpha1A-adrenoreceptors, which results in the relaxation of ureteral smooth muscle.    Current evidence suggests alpha-blockers may be useful when ureteral stones are 5-10 mm; however, there is no evidence to support the use of alpha-blockers with stones <5 mm.  Patients with ureteral stones >10 mm were excluded from studies utilizing these medications.

The size of most ureteral stones will be unknown due to the lack of need for imaging able to measure stone size. Given that the median ureteral stone size is <5 mm, most patients will not benefit from the use of an alpha-blocker.

Also, keep in mind that the data for adverse events with alpha-blockers used for ureteral stones is limited and that these medications have a risk of hypotension.

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Background:

There is an increased incidence of venous thromboembolic events (VTE) in pediatrics due to improved diagnosis and survival of children with VTE.

The mortality rate is estimated at 2%.

The most common etiologies vary by age - Central venous catheters in neonates and infants, and inherited thrombophilia in children and adolescents.

Learning Points:

1. With neonates and infants, carefully assess medical history from neonatal period. Umbilical lines? PICC? Broviac? History of these is likely to be the cause.

2. In children and adolescents, unprovoked VTE is most likely due to inherited thrombophilia, and can be DVT, PE, Portal venous thrombus, etc.

   1. Antithrombin deficiency: The first discovered inherited thrombophilia. The result is a lack of inhibition of coagulation factors – IIa, IXa, Xa, XIIa.

   2. Protein C or/and S deficiency: The result is lack of inhibition of activated Factor V.

   3. Factor V Leiden: Most common inherited thrombophilic defect. Resultant activated Factor V is resistant to normal Protein C and S activity.

   4. Prothrombin Mutation: Second most common inherited thrombophilia. The result is increased levels of prothrombin, which increases the half-life of factor Va.

3. Initial treatment of clinically significant VTE can start with enoxaparin (1-1.5 mg/kg q12-24h, while checking Anti-Xa levels 4 hours after administration for therapeutic dosing.)

Pearl: Testing for thrombophilia is not always appropriate when diagnosing pediatric patients with their first VTE, but in children and adolescents with first diagnosed, unprovoked VTE, it is worthwhile to send off the initial hypercoaguability work up as this can affect the duration of treatment and need for testing or evaluation. Enoxaparin is a recommended medication to start therapeutic treatment of VTE, even in pediatric patients.

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• Most poisonous substance known to man
• LD50 oral dose 1 mcg/kg
• Heat labile single polypeptide chain undergoes proteolytic clevage irreverisibly binds  and blocks cholinergic transmission causing a deadly neuroparalytic syndrome
• Rx: Botulin antitoxin (equine derived against Clostriduim botulinum A,B,E)

• Highly toxic, restricted availability is rapidly absorbed and metabolized to methylmercury crosses CNS
• LD50 of 50 mcg/kg means a dose as little as 0.1ml can result in severe poisoning
• Death of Darmouth inorganic chemist Karen Wetterhahn who spilled a few drops on back of her latex gloved hand, quickly permeated, and absorbed causing severe neurotoxocity and death 10 months later
• Rx: Chelation

VX ("venomous agent X") 

• Organophosphate nerve agent has been used as chemical weapon
• Colorless, odorless, low volatility, and high lipophilicity
• LD50 of 0.04mg/kg (10 mg). Death can occur within 15 minutes after absorption
• Blocks acetylcholinesterase enzyme causing excess accumulation of acetylcholine at the neurojunction and cholinergic poisoning
• Rx: Decontamination, Atropine, 2-PAM

• 100 fresh and salt water varieties (pufferlike fish/blue ringed octopus, frogs)
• Heat stable, water soluble found in fish skin, liver, ovaries,intestine, and muscle
• 25 mg (0.000881 oz) expected to be lethal to a 75 kg person
• Neurotoxicity by inhibition of Na-K pump and blockade neuromuscular transmission
• Rx: Supportive measures

LD50 expresses the dose at which 50% of exposed population will die as a result of exposure.

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Background: Sedation and analgesia are key components for mechanically ventilated patients. While significant data exists regarding how to manage sedation and analgesia in the ICU setting, very little data exists on management in the ED.

Data: A prospective, single-center, observational study of mechanically-ventilated adult patients used linear regression to identify ED sedation practices and outcomes, with a focus on sedation characteristics using the Richmond Agitation-Sedation Scale (RASS).

Findings:

• 15% of intubated patients had no sedation or analgesia ordered
• 64% of intubated patients were documented as deeply-sedated (RASS -3 to -5)
• Deep sedation was not only associated with more ventilator days, but also increased mortality, with an adjusted OR of 0.77 (95% CI 0.54-0.94) favoring patients with lighter sedation.

Bottom line:  Avoid early deep sedation in your intubated patients as this may be directly associated with increased mortality. Instead, a goal RASS of 0 to -2 should be appropriate for most non-paralyzed, mechanically-ventilated ED patients, extrapoloating from ICU guidelines.

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There is tremendous interest in identifying factors that may influence outcome from sports related concussion.

The strongest predictor of slower recovery is the severity of symptoms in the 1-2 days post injury

     -Fewer Sx's in this time period predict a quicker recovery

Pre injury history of mental health problems, depression or migraine headaches predict a longer recovery course

Teenagers might be more vulnerable to having persistent symptoms with greater risk for girls than boys

Having a prior concussion is a risk for having a future concussion

The large majority of injured athletes recover from a clinical perspective within the first month of injury many within the first 10 days

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Bottom line:

There are no absolute contraindications (including age) for epinephrine in patients with anaphylaxis.  Give the initial dose IM into the anterolateral thigh.

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Full cohort analysis idarucizumab for dabigatran associated bleeding was recently published in NEJM.

This study evaluated the laboratory correction of elevated ecarin clotting time or diluted thrombin time induced by dabigatran and time to either cessation of bleeding (Group A: patients with GI bleeding, traumatic bleeding, or ICH) or time to surgery (Group B: patients requiring surgical intervention within 8 hours).

Findings

Group A (n=301): Median time to the cessation of bleeding was 2.5 hours in 134 patients.

HOWEVER:

• Bleeding cessation could not be determined in 67 patients
• Cessation of bleeding could not be assess in 98 patients with ICH
• Bleeding stopped spontaneously in 2 patients.

Group B (n=202): Median time to intended surgery after infusion of idarucizumab was 1.6 hours.

• Normal hemostasis in 184 patients (93.4%), mildly abnormal in 10, and moderately abnormal in 3.
• Many received PRBC and other blood products during surgery

Laboratory markers:

100% reversal of abnormal ecarin clotting time or diluted thrombin time within 4 hours after the administration

Mortality

• 5 Day: Group A: 6.3% vs. Group B: 12.6%
• 30 Day: Group A: 13.5% vs. Group B: 12.6%
• 90 Day: Group A: 18.8% vs. Group B: 18.9%

Conclusion

Authors concluded thate idaurcizumab is an "effective" reversal agent for dabigatran.

Overall, the findings are more promising compared to the interim analysis that was published in 2015.

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• CSF:blood glucose ratio is a useful characteristic in differentiating bacterial meningitis from viral meningitis. 
• Normal CSF glucose is at least 2/3 of serum glucose level.
• In bacterial meningitis, CSF:blood glucose ratio is usually <0.4
• Rousseau et al. conducted a study comparing CSF:blood glucose ratio obtained using a bedside glucometer with the laboratory.
• They found the optimal cutoff of CSF:blood glucose ratio using a bedside glucometer is 0.46 compared to 0.44 using the laboratory.
• This proof-of-concept study suggests that a point-of-care glucometer can be used for rapid diagnosis of abnormal CSF:blood glucose ratio in the evaluation of meningitis.

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Hyponatremic Encephalopathy

• Hyponatremic encephalopathy is a true emergency and due to hypoosmolar-induced cerebral edema.
• In contrast to the asymptomatic patient with hyponatremia, treatment of hyponatremic encephalopathy is determined by symptoms and not the duration of hyponatremia.
• Clinical manifestations include nausea, vomiting, headache, confusion, seizures, respiratory failure, and coma.
• Hypertonic saliine is the treatment of choice
  • Administer 2 ml/kg 3% hypertonic saline (100 ml in many cases)
  • This will typically raise serum sodium 2 mEq/L
  • In most cases, a 4-6 mEq/L rise will reverse neurologic symptoms

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Febrile seizures occur in children 6 months through 5 year olds.  A complex febrile seizure occurs when the seizure is focal, prolonged (> 15 min), or occurs more than once in 24 hours.

The prevalence of bacterial meningitis in children with fever and seizure after the H flu and Strep pneumomoniae vaccine was introduced is 0.6% to 0.8%.  The prevalence of bacterial meningitis is 5x higher after a complex than simple seizure.

From the study referenced, those children with complex febrile seizures who had meningitis all had clinical exam findings suggestive of meningitis.  More studies are needed to provide definitive guidelines about when lumbar punctures are needed in these patients.

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In patients presenting to the ED with suicidal ideation, physicians should not use currently available risk-assessment tools in isolation to identify low-risk patients who are safe for discharge. The best approach to determine risk is an appropriate psychiatric assessment and good clinical judgment, taking patient, family, and community factors into account. (Level C Recommendation, based upon the quality of the research.) 

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Catastrophic Antiphospholipid Syndrome (CAPS):

A life-threatening “thrombotic storm” of multi-organ micro & macro thrombosis in patients with antiphospholipid syndrome (known or unknown).

Triggered circulating antibodies (usually by infection, but can be prompted by malignancy, pregnancy, and lupus itself) cause endothelial disruption and inflammation leading to prothrombotic state, commonly with SIRS response.

Mortality is high at an estimated 40%.

Confirm diagnosis with antiphospholipid antibody titers.

Treat ASAP with unfractionated heparin, corticosteroids, and Hematology consultation for plasma exchange and/or IVIG.

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• It most commonly occurs in patients with preexisting pituitary adenomas, but 3 out of 4 patients with pituitary adenomas are unaware of their diagnosis.
• Patients may acutely present with thunderclap headache, with or without visual field deficits or cranial nerve dysfunction. They may also have meningeal symptoms due to extravasation of blood into the subarachnoid space.
• Endocrine dysfunction is common but not readily diagnosed in the ED.
• Symptoms may be triggered by some hormonal treatments (e.g. GnRH agonists for prostate CA), head trauma, angiographic procedures, or anticoagulation therapy.
• CT is diagnostic in only one-third of cases, but can reveal the intrasellar mass in 80% of cases, and therefore should be the initial test. Blood may be missed in subacute cases.
• MRI is the test of choice, with a sensitivity of over 90%.  

Bottomline: Keep pituitary apoplexy in your differential when considering SAH or meningitis, especially in the presence of risk factors, and have a low threshold to order an MRI. 

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Take Home Point: In patients with diabetic gastroparesis, haloperidol may be an effective adjunctive treatment to prevent hospitalizations and reduce opioid requirements. 

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Patients with psychiatric disorders are found globally, with a recent global burden of disease estimate that mental illness accounted for 32.4% of years lived with disability and 13.0% of disability-adjusted life-years.

The American College of Emergency Physicians just published a methodological rigorous clinical policy entitled “Critical Issues in the Diagnosis and Management of the Adult Psychiatric Patient in the Emergency Department.”

One question they sought to answer was “In the alert adult patient presenting to the ED with acute psychiatric symptoms, should routine laboratory tests be used to identify contributory medical conditions (nonpsychiatric disorders)?”

Their assessment was: “Do not routinely order laboratory testing on patients with acute psychiatric symptoms. Use medical history, previous psychiatric diagnoses, and physician examination to guide testing.” This was a Level C recommendation, based upon the quality of the research.

Bottom Line: Current literature does not support routinely ordering laboratory testing on patients with acute psychiatric symptoms. However, the quality of the evidence was not strong and local clinical context should be considered.

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--RV systolic function is negatively affected by high RV afterload

--High mean airway pressures on the ventilator (particularly in modes such as APRV [airway pressure release ventilation]) can induce RV dysfunction

*****CLICK BELOW FOR A GREAT CASE!!!*****

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The answer appears to be ... it depends.

Early Oseltamivir Treatment in Influenza in Children1-3 Years of Age: A Randomized Controlled Trial

A study in 2010 out of Finland by Heinonen, et al showed that if given in the first 12 hours of symptom onset to otherwise healthy pediatric patients between the age of 1-3 years:

-  decrease incidence of acute otitis media by 85%

-  no difference if given within 24 hours

Among children with influenza A, oseltamivir started within 24 hours of symptom onset

-  shortened medium time to resolution of illness by 3.5 days (3.0 versus 6.5) in all children

- shortened median time to resolution of illness by 4.0 days in UNvaccinated children

- Reduced parental work absenteeism by 3 days

*  no differences were seen in children with influenza B *

Limitations***

- Single Center study in Finland

- The authors received support from the drug manufacturer

- The sample size of children with confirmed influenza cases with small (influenza A: 79, influenza B: 19)

Takeaway:

If you have a patient between the age of 1-3 years with very early symptoms concerning for flu, a positive rapid influenza A test could allow you to cut her symptoms by 3 days, prevent complications, and allow parents to go back to work sooner.

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Patients with severe salicylate poisoning may require endotracheal intubation due to fatigue from hyperventilation or mental status change.

A previously published study (Stolbach et al. 2008) showed that mechanical ventilation increases the risk of acidemia and clinical deterioration.

A small retrospective study investigated the impact of hemodialysis (HD) in intubated patients with salicylate poisoning.

Findings:

53 cases with overall survival rate of 73.2%

In patients with salicylate level > 50 mg/dL

• No HD: 56% survival (14/25)
• HD: 83.9% survival (0/9)

If salicylate level > 80 mg/dL

• No HD: 0% survival (26/31)
• HD: 83.3% survival (15/18)

Bottom Line:

There is moratality benefit of HD in intubated salicylate-poisoned patient.

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Improving Resuscitation Performance

• Resuscitating the critically ill patient can often be quite stressful.
• Stress has been shown to decrease the quality and effectiveness of decisions, decrease the amount of information a person can process, and lead to short-term memory deficits.
• Recently, there has been emphasis on the use of performance-enhancing psychological skills (PEPS) to allow providers to think clearly, maintain situational awareness, recall important information, and perform skills efficiently.
• A recent article highlights 4 key elements of an EM model for PEPS that can be used to improve performance in resuscitations.
  • Breathe - consider tactical breathing
  • Talk - positive instructional or motivational self-talk
  • See - visualize the steps of a procedure before actually performing it
  • Focus - use a trigger word as a prompt to shift attention to a prioritized task

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