Academic journal
POPULARITY
20 episodes with j emerg med
20 episodes with j emerg med
6 episodes with j emerg med
4 episodes with j emerg med
3 episodes with j emerg med
3 episodes with j emerg med
2 episodes with j emerg med
2 episodes with j emerg med
2 episodes with j emerg med
Dr. Trina Augustin, assistant professor of both anesthesiology and perioperative medicine as well as emergency medicine takes us on a deep dive into the care of persons with aortic stenosis. In this chapter, Alex and Venk learn about how to use ultrasound to diagnose AS, the keys to resuscitation, the pathophysiology of this condition, as well as the value of consultative services and the potential interventions that they may unlock for these patients. Kickoff season 4 with this in depth reminder that sometimes the heart has many hidden perils beyond ACS. CONTACTS X - @AlwaysOnEM; @VenkBellamkonda YouTube - @AlwaysOnEM; @VenkBellamkonda Instagram – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch; @KatrinaJoyAugustin Email - AlwaysOnEM@gmail.com REFERENCES & LINKS Lichtenstein DA, Meziere GA. Relevance of Lung Ultrasound in the Diagnosis of Acute Respiratory Failure. Chest 2008; 134:117-125 Walsh MH, Smyth LM, Desy JR, Fischer EA, Goffi A, Li N, Lee M, St-Pierre J, Ma IWY. Lung Ultrasound: A Comparison of image interpretation accuracy between curvillinear and phased array transducers. Australia J Ultrasound Med, 26:150-156 Alzahrani H, Woo MY, Johnson C, Pageau P, Millington S, Thiruganasambandamoorthy V. Can severe aortic stenosis be identified by emergency physicians when interpreting a simplified two-view echocardiogram obtained by trained echocardiographers? Crit Ultrasound J. 2015 Apr 18;7:5. doi: 10.1186/s13089-015-0022-8. PMID: 25932319; PMCID: PMC4409610. Furukawa A, Abe Y, Morizane A, Miyaji T, Hosogi S, Ito H. Simple echocardiographic scoring in screening aortic stenosis with focused cardiac ultrasonography in the emergency department. J Cardiol. 2021 Jun;77(6):613-619. doi: 10.1016/j.jjcc.2020.12.006. Epub 2020 Dec 29. PMID: 33386216. Lin J, Drapkin J, Likourezos A, Giakoumatos E, Schachter M, Sarkis JP, Moskovits M, Haines L, Dickman E. Emergency physician bedside echocardiographic identification of left ventricular diastolic dysfunction. American Journal of Emergency medicine Ehrman RR, Russell FM, Ansari AH, Margeta B, Clary JM, Christian E, Cosby KS, Bailitz J. Can emergency physicians diagnose and correctly classify diastolic dysfunction using bedside echocardiography? Am J Emerg Med. 2015 Sep;33(9):1178-83. doi: 10.1016/j.ajem.2015.05.013. Epub 2015 May 21. PMID: 26058890.2021;44:20-25 Del Rios M, Colla J, Kotini-Shah P, Briller J, Gerber B, Prendergast H. Emergency physician use of tissue Doppler bedside echocardiography in detecting diastolic dysfunction: an exploratory study. Crit Ultrasound J. 2018 Jan 25;10(1):4. doi: 10.1186/s13089-018-0084-5. PMID: 29372430; PMCID: PMC5785451. Thiele H, Zeymer U, Neumann FJ, Ferenc M, Olbrich HG, Hausleiter J, de Waha A, Richardt G, Hennersdorf M, Empen K, Fuernau G, Desch S, Eitel I, Hambrecht R, Lauer B, Böhm M, Ebelt H, Schneider S, Werdan K, Schuler G; Intraaortic Balloon Pump in cardiogenic shock II (IABP-SHOCK II) trial investigators. Intra-aortic balloon counterpulsation in acute myocardial infarction complicated by cardiogenic shock (IABP-SHOCK II): final 12 month results of a randomised, open-label trial. Lancet. 2013 Nov 16;382(9905):1638-45. doi: 10.1016/S0140-6736(13)61783-3. Epub 2013 Sep 3. PMID: 24011548. Aksoy O, Yousefzai R, Singh D, Agarwal S, O'Brien B, Griffin BP, Kapadia SR, Tuzcu ME, Penn MS, Nissen SE, Menon V. Cardiogenic shock in the setting of severe aortic stenosis: role of intra-aortic balloon pump support. Heart. 2011 May;97(10):838-43. doi: 10.1136/hrt.2010.206367. Epub 2010 Oct 20. PMID: 20962337. Karatolios K, Chatzis G, Luesebrink U, Markus B, Ahrens H, Tousoulis D, Schieffer B. Impella support following emergency percutaneous balloon aortic valvuloplasty in patients with severe aortic valve stenosis and cardiogenic shock. Hellenic J Cardiol. 2019 May-Jun;60(3):178-181. doi: 10.1016/j.hjc.2018.02.008. Epub 2018 Mar 21. PMID: 29571667. Gottlieb M, Long B, Koyfman A. Evaluation and Management of Aortic Stenosis for the Emergency Clinician: An Evidence-Based Review of the Literature. J Emerg Med. 2018 Jul;55(1):34-41. doi: 10.1016/j.jemermed.2018.01.026. Epub 2018 Mar 7. PMID: 29525246.
Contributor: Aaron Lessen MD Educational Pearls: Aortic injury occurs in 1.5-2% of patients who sustain blunt thoracic trauma Majority are caused by automobile collisions or motorcycle accidents Due to sudden deceleration mechanism accidents Clinical manifestations Signs of hypovolemic shock including tachycardia and hypotension, though not always present Patients may have altered mental status Imaging Widened mediastinum on chest x-ray, though not highly sensitive CT is more sensitive and specific, and signs of thoracic injury include an intimal flap, aortic wall outpouching, and aortic contour abnormalities In hemodynamically unstable or otherwise unfit for CT patients, transesophageal echocardiogram may be used Four types of aortic injury (in order of ascending severity) I: Intimal tear or flap II: Intramural hematoma III: Pseudoaneurysm IV: Rupture Management Hemodynamically unstable: immediate OR for exploratory laparotomy and repair Hemodynamically stable: heart rate and blood pressure control with beta-blockers Minor injuries are treated with observation and hemodynamic control Severe injuries may receive surgical management Some patients benefit from delayed repair An endovascular aortic graft is a surgical option Mortality 80-85% of patients die before hospital arrival 50% of patients that make it to the hospital do not survive References Fox N, Schwartz D, Salazar JH, et al. Evaluation and management of blunt traumatic aortic injury: a practice management guideline from the Eastern Association for the Surgery of Trauma [published correction appears in J Trauma Acute Care Surg. 2015 Feb;78(2):447]. J Trauma Acute Care Surg. 2015;78(1):136-146. doi:10.1097/TA.0000000000000470 Lee WA, Matsumura JS, Mitchell RS, et al. Endovascular repair of traumatic thoracic aortic injury: clinical practice guidelines of the Society for Vascular Surgery. J Vasc Surg. 2011;53(1):187-192. doi:10.1016/j.jvs.2010.08.027 Osgood MJ, Heck JM, Rellinger EJ, et al. Natural history of grade I-II blunt traumatic aortic injury. J Vasc Surg. 2014;59(2):334-341. doi:10.1016/j.jvs.2013.09.007 Osman A, Fong CP, Wahab SFA, Panebianco N, Teran F. Transesophageal Echocardiography at the Golden Hour: Identification of Blunt Traumatic Aortic Injuries in the Emergency Department. J Emerg Med. 2020;59(3):418-423. doi:10.1016/j.jemermed.2020.05.003 Steenburg SD, Ravenel JG, Ikonomidis JS, Schönholz C, Reeves S. Acute traumatic aortic injury: imaging evaluation and management. Radiology. 2008;248(3):748-762. doi:10.1148/radiol.2483071416 Summarized by Jorge Chalit, OMS3 | Edited by Meg Joyce & Jorge Chalit Donate: https://emergencymedicalminute.org/donate/
Laboring Under Pressure Episode 4: Obstetric Emergency in South Africa with Dr. Meghan Hurley Contributors: Meghan Hurley MD, Travis Barlock MD, Jeffrey Olson MS3 Show Pearls Map of South Africa Referenced South Africa Geography Lesson There is a big disparity between Cape Town and its neighbor Khayelitsha. Cape Town is the legislative capital and economic hub of South Africa, known for its infrastructure, tourist attractions, and developed urban areas. Khayelitsha Township is a large informal settlement on the outskirts of Cape Town, with limited infrastructure and services compared to the city center. Many residents live in informal housing. This disparity is the lasting effect of how land was divided up and populations were moved around during Apartheid. Apartheid was a policy of segregation that lasted from 1948 to 1994. How does medical education work in South Africa? Medical education in South Africa typically follows a 6-year undergraduate program directly after high school Registrars our the equivalent of Resident in America. They are graduated doctors who work in hospitals under the supervision of senior doctors as they progress toward becoming specialists. Pearls from the case and the discussion afterward Whole blood from a draw can be used instead of urine on a POC pregnancy test. Wait a little bit longer before making a determination because blood is more viscous. Although the casettes are not approved for whole blood several studies have shown this to be efficacious. Free fluid in the abdomen and a pregnancy of unknown location is a rupture ectopic until proven otherwise. Appendicitis can present on the left side. Most commonly from an extra appendix, but can also result from situs inversus or mid-gut malrotation. This presentation can also be the result of an atypically large appendix. Fever is common in appendicitis (~40%) and becomes less common with older patients. Don't be falsely reassured by a normal hemoglobin in acute bleeding because patients bleed whole blood and the hemoglobin concentration is not affected. These patients should be resuscitated with whole blood. Give rhesus factor negative blood to female patients of childbearing age to prevent them from developing antibodies to the rhesus factor which can lead to Rh disease in future pregnancies. Rhogam can be given in cases of ruptured ectopic pregnancies to lower the risk of alloimmunization. Blood transfusions carry the risk of lung and heart injury from the extra volume. The treatment for this condition is to diurese the patient. Other topics discussed include the complications of working in a South African township hospital at night, the epidemiology of burns, and the importance of global health. References Akbulut S, Ulku A, Senol A, Tas M, Yagmur Y. Left-sided appendicitis: review of 95 published cases and a case report. World J Gastroenterol. 2010 Nov 28;16(44):5598-602. doi: 10.3748/wjg.v16.i44.5598. PMID: 21105193; PMCID: PMC2992678. Barash, J. H., Buchanan, E. M., & Hillson, C. (2014). Diagnosis and management of ectopic pregnancy. American family physician, 90(1), 34–40. Fromm C, Likourezos A, Haines L, Khan AN, Williams J, Berezow J. Substituting whole blood for urine in a bedside pregnancy test. J Emerg Med. 2012 Sep;43(3):478-82. doi: 10.1016/j.jemermed.2011.05.028. Epub 2011 Aug 27. PMID: 21875776. Moris, D., Paulson, E. K., & Pappas, T. N. (2021). Diagnosis and Management of Acute Appendicitis in Adults: A Review. JAMA, 326(22), 2299–2311. https://doi.org/10.1001/jama.2021.20502 Sowder AM, Yarbrough ML, Nerenz RD, Mitsios JV, Mortensen R, Gronowski AM, Grenache DG. Analytical performance evaluation of the i-STAT Total β-human chorionic gonadotropin immunoassay. Clin Chim Acta. 2015 Jun 15;446:165-70. doi: 10.1016/j.cca.2015.04.025. Epub 2015 Apr 25. PMID: 25916696. Produced by Jeffrey Olson, MS3 | Edited by Jeffrey Olson and Jorge Chalit, OMSIII
In this episode, Dr. Sergio Zanotti discuss the management of critically ill patients undergoing hyperglycemic emergencies. He is joined by Dr. George Willis, a practicing emergency medicine physician. Dr. Willis is an Associate Professor and Associate Program Director for Emergency Medicine at the University of Texas Health Science Center in San Antonio, where he also serves as Vice Chair of Faculty Affairs. A recognized clinical educator, he holds a particular interest in endocrine emergencies, vascular emergencies, procedural education, and medical education. Additional resources: Hyperglycemic Crises in Adults with Diabetes: A Consensus Report. GE Umpierez, et al. Diabetes Care 2024: https://diabetesjournals.org/care/article/47/8/1257/156808/Hyperglycemic-Crises-in-Adults-With-Diabetes-A Clinical Effects of Balanced Crystalloids vs Saline in Adults With Diabetic Ketoacidosis. WH Self, et al. JAMA 2020: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7670314/ Evaluation and Management of the Critically Ill Adult with Diabetic Ketoacidosis. B Long, GC Willis, S Lentz, et al. J Emerg Med 2020: https://pubmed.ncbi.nlm.nih.gov/32763063/ The SQuID protocol (subcutaneous insulin in diabetic ketoacidosis) Impacts on ED operational Metrics. Acad Emerg Med 2023: https://pubmed.ncbi.nlm.nih.gov/36775281/ Books mentioned in this episode: Kintsugi: Finding Strength in Imperfection. By Celine Santini: https://bit.ly/3NCdAYB
Welcome to Episode 37 of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Show Notes for Episode 37 of “The 2 View” – Pitfalls in Managing Pain in the ED with Sergey M. Motov, MD, FAAEM. Segment 1 Bachhuber MA, Hennessy S, Cunningham CO, Starrels JL. Increasing Benzodiazepine Prescriptions and Overdose Mortality in the United States, 1996-2013. Am J Public Health. 2016;106(4):686-688. doi:10.2105/AJPH.2016.303061. https://pubmed.ncbi.nlm.nih.gov/26890165/ Bijur PE, Kenny MK, Gallagher EJ. Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients. Ann Emerg Med. 2005;46(4):362-367. doi:10.1016/j.annemergmed.2005.03.010. https://pubmed.ncbi.nlm.nih.gov/16187470/ Evoy KE, Covvey JR, Peckham AM, Ochs L, Hultgren KE. Reports of gabapentin and pregabalin abuse, misuse, dependence, or overdose: An analysis of the Food And Drug Administration Adverse Events Reporting System (FAERS). Res Social Adm Pharm. 2019;15(8):953-958. doi:10.1016/j.sapharm.2018.06.018. https://pubmed.ncbi.nlm.nih.gov/31303196/ Kim HS, McCarthy DM, Hoppe JA, Mark Courtney D, Lambert BL. Emergency Department Provider Perspectives on Benzodiazepine-Opioid Coprescribing: A Qualitative Study. Acad Emerg Med. 2018;25(1):15-24. doi:10.1111/acem.13273. https://pubmed.ncbi.nlm.nih.gov/28791786/ Li Y, Delcher C, Wei YJ, et al. Risk of Opioid Overdose Associated With Concomitant Use of Opioids and Skeletal Muscle Relaxants: A Population-Based Cohort Study. Clin Pharmacol Ther. 2020;108(1):81-89. doi:10.1002/cpt.1807. https://pubmed.ncbi.nlm.nih.gov/32022906/ Peckham AM, Evoy KE, Covvey JR, Ochs L, Fairman KA, Sclar DA. Predictors of Gabapentin Overuse With or Without Concomitant Opioids in a Commercially Insured U.S. Population. Pharmacotherapy. 2018;38(4):436-443. doi:10.1002/phar.2096. https://pubmed.ncbi.nlm.nih.gov/29484686/ Smith RV, Havens JR, Walsh SL. Gabapentin misuse, abuse and diversion: a systematic review. Addiction. 2016;111(7):1160-1174. doi:10.1111/add.13324. https://pubmed.ncbi.nlm.nih.gov/27265421/ Suvada K, Zimmer A, Soodalter J, Malik JS, Kavalieratos D, Ali MK. Coprescribing of opioids and high-risk medications in the USA: a cross-sectional study with data from national ambulatory and emergency department settings. BMJ Open. 2022;12(6):e057588. Published 2022 Jun 16. doi:10.1136/bmjopen-2021-057588. https://pubmed.ncbi.nlm.nih.gov/35710252/ Segment 2 Caplan M, Friedman BW, Siebert J, et al. Use of clinical phenotypes to characterize emergency department patients administered intravenous opioids for acute pain. Clin Exp Emerg Med. 2023;10(3):327-332. doi:10.15441/ceem.23.018. https://pubmed.ncbi.nlm.nih.gov/37092185/ Connors NJ, Mazer-Amirshahi M, Motov S, Kim HK. Relative addictive potential of opioid analgesic agents. Pain Manag. 2021;11(2):201-215. doi:10.2217/pmt-2020-0048. https://pubmed.ncbi.nlm.nih.gov/33300384/ Fassassi C, Dove D, Davis A, et al. Analgesic efficacy of morphine sulfate immediate release vs. oxycodone/acetaminophen for acute pain in the emergency department. Am J Emerg Med. 2021;46:579-584. doi:10.1016/j.ajem.2020.11.034. https://pubmed.ncbi.nlm.nih.gov/33341323/ Irizarry E, Cho R, Williams A, et al. Frequency of Persistent Opioid Use 6 Months After Exposure to IV Opioids in the Emergency Department: A Prospective Cohort Study. J Emerg Med. Published online March 14, 2024. doi:10.1016/j.jemermed.2024.03.018. https://pubmed.ncbi.nlm.nih.gov/38821847/ Sapkota A, Takematsu M, Adewunmi V, Gupta C, Williams AR, Friedman BW. Oxycodone induced euphoria in ED patients with acute musculoskeletal pain. A secondary analysis of data from a randomized trial. Am J Emerg Med. 2022;53:240-244. doi:10.1016/j.ajem.2022.01.016. https://pubmed.ncbi.nlm.nih.gov/35085877/ Wightman R, Perrone J, Portelli I, Nelson L. Likeability and abuse liability of commonly prescribed opioids. J Med Toxicol. 2012;8(4):335-340. doi:10.1007/s13181-012-0263-x. https://pubmed.ncbi.nlm.nih.gov/22992943/ Segment 3 Anshus AJ, Oswald J. Erector spinae plane block: a new option for managing acute axial low back pain in the emergency department. Pain Manag. 2021;11(6):631-637. doi:10.2217/pmt-2021-0004. https://pubmed.ncbi.nlm.nih.gov/34102865/ Chauhan G, Burke H, Srinivasan SK, Upadhyay A. Ultrasound-Guided Erector Spinae Block for Refractory Abdominal Pain Due to Acute on Chronic Pancreatitis. Cureus. 2022;14(11):e31817. Published 2022 Nov 23. doi:10.7759/cureus.31817. https://pubmed.ncbi.nlm.nih.gov/36579238/ Dove D, Fassassi C, Davis A, et al. Comparison of Nebulized Ketamine at Three Different Dosing Regimens for Treating Painful Conditions in the Emergency Department: A Prospective, Randomized, Double-Blind Clinical Trial. Ann Emerg Med. 2021;78(6):779-787. doi:10.1016/j.annemergmed.2021.04.031. https://pubmed.ncbi.nlm.nih.gov/34226073/ Elkoundi A, Eloukkal Z, Bensghir M, Belyamani L, Lalaoui SJ. Erector Spinae Plane Block for Hyperalgesic Acute Pancreatitis. Pain Med. 2019;20(5):1055-1056. doi:10.1093/pm/pny232. https://pubmed.ncbi.nlm.nih.gov/30476275/ Finneran Iv JJ, Gabriel RA, Swisher MW, Berndtson AE, Godat LN, Costantini TW, Ilfeld BM. Ultrasound-guided percutaneous intercostal nerve cryoneurolysis for analgesia following traumatic rib fracture -a case series. Korean J Anesthesiol. 2020 Oct;73(5):455-459. doi: 10.4097/kja.19395. Epub 2019 Nov 5. PMID: 31684715; PMCID: PMC7533180. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7533180/ Finneran JJ, Swisher MW, Gabriel RA, et al. Ultrasound-Guided Lateral Femoral Cutaneous Nerve Cryoneurolysis for Analgesia in Patients With Burns. J Burn Care Res. 2020;41(1):224-227. doi:10.1093/jbcr/irz192. https://pubmed.ncbi.nlm.nih.gov/31714578/ Gabriel RA, Finneran JJ, Asokan D, Trescot AM, Sandhu NS, Ilfeld BM. Ultrasound-Guided Percutaneous Cryoneurolysis for Acute Pain Management: A Case Report. A A Case Rep. 2017;9(5):129-132. doi:10.1213/XAA.0000000000000546. https://pubmed.ncbi.nlm.nih.gov/28509777/ Herring AA, Stone MB, Nagdev AD. Ultrasound-guided abdominal wall nerve blocks in the ED. Am J Emerg Med. 2012;30(5):759-764. doi:10.1016/j.ajem.2011.03.008. https://pubmed.ncbi.nlm.nih.gov/21570238/ Kampan S, Thong-On K, Sri-On J. A non-inferiority randomized controlled trial comparing nebulized ketamine to intravenous morphine for older adults in the emergency department with acute musculoskeletal pain. Age Ageing. 2024;53(1):afad255. doi:10.1093/ageing/afad255. https://pubmed.ncbi.nlm.nih.gov/38251742/ Mahmoud S, Miraflor E, Martin D, Mantuani D, Luftig J, Nagdev AD. Ultrasound-guided transverse abdominis plane block for ED appendicitis pain control. Am J Emerg Med. 2019;37(4):740-743. doi:10.1016/j.ajem.2019.01.024. https://pubmed.ncbi.nlm.nih.gov/30718116/ McCahill RJ, Nagle C, Clarke P. Use of Virtual Reality for minor procedures in the Emergency Department: A scoping review. Australas Emerg Care. 2021;24(3):174-178. doi:10.1016/j.auec.2020.06.006. https://pubmed.ncbi.nlm.nih.gov/32718907/ Nguyen T, Mai M, Choudhary A, et al. Comparison of Nebulized Ketamine to Intravenous Subdissociative Dose Ketamine for Treating Acute Painful Conditions in the Emergency Department: A Prospective, Randomized, Double-Blind, Double-Dummy Controlled Trial. Ann Emerg Med. Published online May 2, 2024. doi:10.1016/j.annemergmed.2024.03.024. https://pubmed.ncbi.nlm.nih.gov/38703175/ Sikka N, Shu L, Ritchie B, Amdur RL, Pourmand A. Virtual Reality-Assisted Pain, Anxiety, and Anger Management in the Emergency Department. Telemed J E Health. 2019;25(12):1207-1215. doi:10.1089/tmj.2018.0273. https://pubmed.ncbi.nlm.nih.gov/30785860/ Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. Theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. Thesgem.com. http://www.thesgem.com Trivia Question: Send answers to 2viewcast@gmail.com Be sure to keep tuning in for more great prizes and fun trivia questions! Once you hear the question, please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to. 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In this second of a two part podcast special Iain and Simon go through twenty of the top papers from the last year or so, as presented by Simon at the Big Sick Conference in Zermatt earlier this year. All the details and more discussion can be found on the blog site. In Part 2 they discuss papers about major haemorrhage, trauma, cardiac arrest and more. In Part 1 they discuss all things airway, including where we should be intubating patients needing immediate haemorrhage control. VL vs DL, the effect of blade size on intubation success, whether small adult ventilation bags are better than larger versions, intubating comatose poisoned patients, and more. Papers Jansen JO et al. Emergency Department Resuscitative Endovascular Balloon Occlusion of the Aorta in Trauma Patients With Exsanguinating Hemorrhage: The UK-REBOA Randomized Clinical Trial. JAMA. 2023 Nov 21;330(19):1862-1871. doi: 10.1001/jama.2023.20850. PMID: 37824132; PMCID: PMC10570916. Davenport R et al. Early and Empirical High-Dose Cryoprecipitate for Hemorrhage After Traumatic Injury: The CRYOSTAT-2 Randomized Clinical Trial. JAMA. 2023 Nov 21;330(19):1882-1891. doi: 10.1001/jama.2023.21019. PMID: 37824155; PMCID: PMC10570921. PATCH-Trauma Investigators and the ANZICS Clinical Trials Group; Prehospital Tranexamic Acid for Severe Trauma. N Engl J Med. 2023 Jul 13;389(2):127-136. doi: 10.1056/NEJMoa2215457. Epub 2023 Jun 14. PMID: 37314244. Shepherd JM et al Safety and efficacy of artesunate treatment in severely injured patients with traumatic hemorrhage. The TOP-ART randomized clinical trial. Intensive Care Med. 2023 Aug;49(8):922-933. doi: 10.1007/s00134-023-07135-3. Epub 2023 Jul 20. PMID: 37470832; PMCID: PMC10425486. Bouzat P et al. Efficacy and Safety of Early Administration of 4-Factor Prothrombin Complex Concentrate in Patients With Trauma at Risk of Massive Transfusion: The PROCOAG Randomized Clinical Trial. JAMA. 2023 Apr 25;329(16):1367-1375. doi: 10.1001/jama.2023.4080. PMID: 36942533; PMCID: PMC10031505. Torres CM, Kent A, Scantling D, Joseph B, Haut ER, Sakran JV. Association of Whole Blood With Survival Among Patients Presenting With Severe Hemorrhage in US and Canadian Adult Civilian Trauma Centers. JAMA Surg. 2023 May 1;158(5):532-540. doi: 10.1001/jamasurg.2022.6978. Erratum in: JAMA Surg. 2023 Apr 5;: PMID: 36652255; PMCID: PMC9857728. Marsden MER, Kellett S, Bagga R, Wohlgemut JM, Lyon RL, Perkins ZB, Gillies K, Tai NR. Understanding pre-hospital blood transfusion decision-making for injured patients: an interview study. Emerg Med J. 2023 Nov;40(11):777-784. doi: 10.1136/emermed-2023-213086. Epub 2023 Sep 13. PMID: 37704359; PMCID: PMC10646861. Wohlgemut JM, Pisirir E, Stoner RS, Kyrimi E, Christian M, Hurst T, Marsh W, Perkins ZB, Tai NRM. Identification of major hemorrhage in trauma patients in the prehospital setting: diagnostic accuracy and impact on outcome. Trauma Surg Acute Care Open. 2024 Jan 12;9(1):e001214. doi: 10.1136/tsaco-2023-001214. PMID: 38274019; PMCID: PMC10806521. Cheskes S, Verbeek PR, Drennan IR, McLeod SL, Turner L, Pinto R, Feldman M, Davis M, Vaillancourt C, Morrison LJ, Dorian P, Scales DC. Defibrillation Strategies for Refractory Ventricular Fibrillation. N Engl J Med. 2022 Nov 24;387(21):1947-1956. doi: 10.1056/NEJMoa2207304. Epub 2022 Nov 6. PMID: 36342151. Siddiqua N, Mathew R, Sahu AK, Jamshed N, Bhaskararayuni J, Aggarwal P, Kumar A, Khan MA. High-dose versus low-dose intravenous nitroglycerine for sympathetic crashing acute pulmonary edema: a randomised controlled trial. Emerg Med J. 2024 Jan 22;41(2):96-102. doi: 10.1136/emermed-2023-213285. PMID: 38050078. Wilkinson-Stokes M, Betson J, Sawyer S. Adverse events from nitrate administration during right ventricular myocardial infarction: a systematic review and meta-analysis. Emerg Med J. 2023 Feb;40(2):108-113. doi: 10.1136/emermed-2021-212294. Epub 2022 Sep 30. PMID: 36180168. Patterson T, Perkins GD, Perkins A, Clayton T, Evans R, Dodd M, Robertson S, Wilson K, Mellett-Smith A, Fothergill RT, McCrone P, Dalby M, MacCarthy P, Firoozi S, Malik I, Rakhit R, Jain A, Nolan JP, Redwood SR; ARREST trial collaborators. Expedited transfer to a cardiac arrest centre for non-ST-elevation out-of-hospital cardiac arrest (ARREST): a UK prospective, multicentre, parallel, randomised clinical trial. Lancet. 2023 Oct 14;402(10410):1329-1337. doi: 10.1016/S0140-6736(23)01351-X. Epub 2023 Aug 27. PMID: 37647928. Issa EC, Ware PJ, Bitange P, Cooper GJ, Galea T, Bengiamin DI, Young TP. The “Syringe Hickey”: An Alternative Skin Marking Method for Lumbar Puncture. J Emerg Med. 2023 Mar;64(3):400-404. doi: 10.1016/j.jemermed.2023.01.013. PMID: 37019501.
The podcast crew is joined by a special guest, Dr. Andrew Partain, an EMS Fellow from UTSW in Dallas. We will dissect his recent data surrounding ketamine-only intubation from MedStar in Fort Worth. This is not just another boring data rehash. There are some vital and applicable pearls that must be applied to the world of prehospital airway management. REFERENCES: 1. Driver BE, Prekker ME, Reardon RF, Sandefur BJ, April MD, Walls RM, Brown CA 3rd. Success and Complications of the Ketamine-Only Intubation Method in the Emergency Department. J Emerg Med. 2021 Mar;60(3):265-272.
BRASH es un acrónimo relativamente nuevo que describe un síndrome de bradicardias con hipotensión severa en el contexto de fallo renal e hiperkalemia. Usted está atendiendo a un masculino de 62 años de edad con debilidad general y desorientación progresivamente peor desde hace varias horas. Mantiene su propia vía aérea y respira espontáneamente, pero no tiene pulsos periféricos palpables. Los signos vitales son 28, 20, 86%, 82/38. Usted coloca al paciente en el monitor cardiaco y observa un bloqueo AV de 3er grado sin ondas P y con un complejo de escape ventricular. De inmediato le coloca oxígeno al paciente mediante mascarilla de no-reinhalación, obtiene dos accesos vasculares, administra 1 mg de atropina y se prepara para realizar intervenciones de segunda línea para aumentar la frecuencia cardiaca, entre ellas, la administración de una infusión de adrenalina y la colocación de un marcapasos externo. Los algoritmos están hechos para evitar desastres. No necesariamente representan el mejor cuidado posible. En este caso, el algoritmo de bradicardia nos dice qué acciones debemos hacer de inicio para mantener al paciente vivo. Sin embargo, no está funcionando. ¿Por qué? Debido a la hiperkalemia. Los medicamentos que causan bloqueo de la conducción a través del nodo atrioventricular (AV) pueden provocar episodios de hipotensión severa y refractaria en el contexto de fallo renal agudo. Bloqueo AV + fallo renal agudo El fallo renal puede ocurrir por cualquier causa no relacionada. El fallo renal pre-renal puede ocurrir, por ejemplo, por deshidratación severa o cualquier otra causa de pobre perfusión sistémica. El fallo renal produce hiperkalemia. La hiperkalemia y el bloqueo del nodo AV por los bloqueadores beta y/o por los bloqueadores de canales de calcio produce la hipotensión. BRASH: un acrónimo a recordar cuando se trata bradicardias sintomáticas Bradicardia Fallo Renal Bloqueo AV Shock Hiperkalemia Cada una de estas condiciones presenta un problema por sí mismo. Cuando se combinan, tienen un efecto sinergístico. Es decir, tiene un efecto más potente que la suma de sus partes individuales. BRASH no es un diagnóstico por separado, sino una descripción de los signos y síntomas asociados al ciclo vicioso de bradicardia, shock, fallo renal e hiperkalemia. Ciclo vicioso de bradicadia, shock, fallo renal e hiperkalemia La bradicardia puede venir por los medicamentos y/o por la hiperkalemia. En el paciente que ya toma estos medicamentos de forma continua, es posible que un deterioro súbito en la función renal de paso a la hiperkalemia. La causa del deterioro súbito de la función renal puede ser por cualquier causa pre-renal, renal o pos-renal. Una causa común de fallo renal pre-renal es cualquier causa de shock que provoque un episodio sostenido de pobre perfusión renal. El resultado es un aumento en los niveles de potasio debido a la pobre eliminación renal. La hiperkalemia produce bloqueo AV y bradicardia, lo que puede agravar aún más la bradicardia y agravar aún más la pobre perfusión renal, lo que provoca a su vez una peor hiperkalemia. SAMPLE El historial clínico del paciente es fundamental para entender el problema. Signos y síntomas Alergias Medicamentos Padecimientos Última ingesta ("last meal") Evento que precedió la emergencia Pistas importantes del historial El historial puede dar a relucir el hecho de que el paciente esté tomando medicamentos que bloquean el nodo AV. Quizás un cambio reciente en la dosis, o la introducción de otro medicamento que tenga un efecto en los niveles de potasio puede ser el detonante reciente. El historial puede dar a relucir el hecho de que el paciente ya padezca de una condición renal previa. El historial puede dar a relucir algún evento reciente que haya provocado el deterioro agudo en la función renal. Trate la bradicardia, la hiperkalemia y la causa de la pobre perfusión El manejo de la bradicardia puede no ser suficiente para lograr estabilizar hemodinámicamente al paciente con BRASH. Es importante reconocer rápidamente y tratar de inmediato de la hiperkalemia. Aunque las ondas T picudas e hiperagudas son signos clásicos de la hiperkalemia, son signos demasiado tempranos. La evolución natural de la condición va a producir bloqueo AV y prolongamiento del complejo QRS. Es decir, es la propia bradicardia y bloqueo AV el mejor signo de que el paciente puede tener una hiperkalemia. Simultáneo al manejo de la bradicardia y de la hiperkalemia, es esencial tratar la causa que está provocando la pobre perfusión renal (por ejemplo, fallo pre-renal por pobre perfusión). Si esto no se corrige, el escenario va a volver a repetirse. Pequeños estímulos con grandes efectos Como mencionado anteriormente, el efecto de esta combinación es sinergístico. Es decir, el efecto combinado es más grande que la suma de sus efectos individuales. No tiene que haber ocurrido un cambio en la dosis que el paciente está tomando del medicamento que bloquea el nodo AV, ni tiene que ser una dosis especialmente alta. Puede ser la misma dosis que ha tomado por largo tiempo sin efectos adversos. Un episodio reciente de deshidratación no tiene que llevar a fallo renal pre-renal. Sin embargo, en presencia del efecto del medicamento que bloquea el nodo AV, tiene un efecto dramático en el riñón. La hiperkalemia no tiene que ser de inicio muy alta. Es decir, no hay una correlación entre niveles específicos de potasio en sangre y los efectos observados. Peor aún, los cambios en el EKG no necesariamente van a progresar de la misma manera que siempre se habla de la hiperkalemia (primero ondas T hiperagudas). Como mencioné anteriormente, la bradicardia quizás es el único indicio. Entonces, cada uno de los estímulos no tiene que ser muy significativo: una dosis normal del medicamento que siempre ha tomado, un episodio relativamente benigno de deshidratación (por ejemplo), un nivel de potasio levemente elevado... pero la combinación produce una bradicardia severa, con fallo renal, bloqueo AV, shock e hiperkalemia... mejor conocido como BRASH. Referencias Arif AW, Khan MS, Masri A, Mba B, Talha Ayub M, Doukky R. BRASH Syndrome with Hyperkalemia: An Under-Recognized Clinical Condition. Methodist Debakey Cardiovasc J. 2020 Jul-Sep;16(3):241-244. doi: 10.14797/mdcj-16-3-241. PMID: 33133361; PMCID: PMC7587309. Farkas JD, Long B, Koyfman A, Menson K. BRASH Syndrome: Bradycardia, Renal Failure, AV Blockade, Shock, and Hyperkalemia. J Emerg Med. 2020 Aug;59(2):216-223. doi: 10.1016/j.jemermed.2020.05.001. Epub 2020 Jun 18. PMID: 32565167. Lizyness K, Dewald O. BRASH Syndrome. [Updated 2023 Mar 27]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK570643/ https://emcrit.org/ibcc/brash/ https://litfl.com/brash-syndrome/
Contributor: Meghan Hurley MD Educational Pearls: What is a nerve block? A nerve block is the medical procedure of injecting anesthetic into the area around a nerve to block pain signals. They are typically done with ultrasound guidance. Are nerve blocks effective? Most of the information we have about nerve blocks is extrapolated from fascia iliaca blocks. This nerve block targets the fascia iliaca compartment, which contains the femoral, lateral femoral cutaneous, and obturator nerves. These blocks are commonly done for hip fractures to help stabilize the patient while awaiting surgical repair. The data for these types of injections is strong. They decrease pain, they decrease total morphine equivalents needed while a patient is in the hospital, they help mobilize patients earlier and start physical therapy earlier, and they help patients leave the hospital about a day earlier. What is an example of an agent that can be used? Bupivacaine. A long acting amide-type local anesthetic. It works best when paired with epinephrine which causes local vasoconstriction and allows the bupivaciaine to bathe the nerve for longer. It gives 5-15 hours of anesthesia (complete sensation loss), and up to 30 hours of analgesia (pain loss). What's an example of another block that can be done? An Erector Spinae Plane (ESP) block is performed in the paraspinal fascial plane in the back. This can be used for pain around the ribs and before a variety of medical procedures including a Nuss procedure, thoracotomies, percutaneous nephrolithotomies, ventral hernia repairs, and even lumbar fusions. What is one potential complication of a nerve block? Local Anesthetic Systemic Toxicity (LAST). There are three ways this can happen: 1) Using too much total anesthetic (Maximum dose of bupivacaine is 2.5 mg/kg). 2) Too much anesthetic is injected into a confined space which then gets absorbed into the venous system. 3) Injecting directly into the vasculature by mistake. What are the signs that this complication has occurred? Perioral tingling Stupor Coma Seizures What can that cause? Cardiovascular collapse How is that treated? Intralipid AKA Soybean Oil, or “lipid emulsion” should be given as a bolus followed by a drip. These patients need to be admitted. Bolus 1.5 ml/kg (lean body mass) intravenously over 1 min (max ~100 ml). Continuous infusion at 0.25 mL/kg/min. Max dosing in the first 30 minutes is around 100 ml/kg. Fun fact: Patients being treated for LAST with intralipid cannot undergo general anesthesia because the intralipid will impact the anesthesia drugs. References Long B, Chavez S, Gottlieb M, Montrief T, Brady WJ. Local anesthetic systemic toxicity: A narrative review for emergency clinicians. Am J Emerg Med. 2022 Sep;59:42-48. doi: 10.1016/j.ajem.2022.06.017. Epub 2022 Jun 13. PMID: 35777259. Carvalho Júnior LH, Temponi EF, Paganini VO, Costa LP, Soares LF, Gonçalves MB. Reducing the length of hospital stay after total knee arthroplasty: influence of femoral and sciatic nerve block. Rev Assoc Med Bras (1992). 2015 Jan-Feb;61(1):40-3. doi: 10.1590/1806-9282.61.01.040. Epub 2015 Jan 1. PMID: 25909207. Jain N, Kotulski C, Al-Hilli A, Yeung-Lai-Wah P, Pluta J, Heegeman D. Fascia Iliaca Block in Hip and Femur Fractures to Reduce Opioid Use. J Emerg Med. 2022 Jul;63(1):1-9. doi: 10.1016/j.jemermed.2022.04.018. Epub 2022 Aug 4. PMID: 35933265. Kot P, Rodriguez P, Granell M, Cano B, Rovira L, Morales J, Broseta A, Andrés J. The erector spinae plane block: a narrative review. Korean J Anesthesiol. 2019 Jun;72(3):209-220. doi: 10.4097/kja.d.19.00012. Epub 2019 Mar 19. PMID: 30886130; PMCID: PMC6547235. Lee SH, Sohn JT. Mechanisms underlying lipid emulsion resuscitation for drug toxicity: a narrative review. Korean J Anesthesiol. 2023 Jun;76(3):171-182. doi: 10.4097/kja.23031. Epub 2023 Jan 26. PMID: 36704816; PMCID: PMC10244607. Weinberg, Guy. LipidRescue™ Resuscitation. http://www.lipidrescue.org/ Summarized by Jeffrey Olson MS2 | Edited by Jorge Chalit, OMSII
MedLink Neurology Podcast is delighted to feature selected episodes from BrainWaves, courtesy of James E Siegler MD, its originator and host. BrainWaves is an academic audio podcast whose mission is to educate medical providers through clinical cases and topical reviews in neurology, medicine, and the humanities, and episodes originally aired from 2016 to 2021. Originally released: October 14, 2018 There is nothing mysterious about the chemistry of the cerebrospinal fluid. Cells. Protein. Glucose. But the interplay of these unique components can give you incredible insight into the state of the central nervous system. This week, we revisit a prior episode where Dr. Mike Rubenstein reviews his approach to interpreting CSF results. And then we have an update at the end regarding recent advances in CSF analysis. Produced by James E Siegler and Michael Rubenstein. Music by Steve Combs. Sound effects by Mike Koenig and Daniel Simion. Voiceover by Patrick Green (German). BrainWaves' podcasts and online content are intended for medical education only and should not be used for clinical decision-making. If you like what you hear, let us know, and rate the show! REFERENCES Deisenhammer F, Bartos A, Egg R, et al. Guidelines on routine cerebrospinal fluid analysis. Report from an EFNS task force. Eur J Neurol 2006;13(9):913-22. PMID 16930354Frederiks JA, Koehler PJ. The first lumbar puncture. J Hist Neurosci 1997;6(2):147-53. PMID 11619518Messacar K, Schreiner TL, Van Haren K, et al. Acute flaccid myelitis: a clinical review of US cases 2012-2015. Ann Neurol 2016;80(3):326-38. PMID 27422805Nagel MA, Cohrs RJ, Mahalingam R, et al. The varicella zoster virus vasculopathies: clinical, CSF, imaging, and virologic features. Neurology 2008;70(11):853-60. PMID 18332343Seehusen DA, Reeves MM, Fomin DA. Cerebrospinal fluid analysis. Am Fam Physician 2003;68(6):1103-8. PMID 14524396Shah KH, Edlow JA. Distinguishing traumatic lumbar puncture from true subarachnoid hemorrhage. J Emerg Med 2002;23(1):67-74. PMID 12217474 We believe that the principles expressed or implied in the podcast remain valid, but certain details may be superseded by evolving knowledge since the episode's original release date.
Contributor: Dylan Luyten MD Educational Pearls: What is a Bradyarrhythmia? Also known as a bradyarrhythmia, it is an irregular heart rate that is also slow (below 60 beats per minute). What can cause it? Complete heart block AKA third-degree AV block; identified on ECG by a wide QRS, and complete dissociation between the atrial and ventricular rhythms with the ventricular being much slower. Treat with a pacemaker. Medication overdose, especially beta blockers. Many other drugs can slow the heart as well including: opioids, clonidine, digitalis, amiodarone, diltiazem, and verapamil to name a few. Electrolyte abnormalities, specifically hyperkalemia. Hypokalemia, hypocalcemia, and hypomagnesemia can also cause bradyarrhythmias. Myocardial infarction. Either by damaging the AV node or the conduction system itself or by triggering a process called Reperfusion Bradycardia. Hypothermia. Bradycardia is generally a sign of severe or advanced hypothermia. References Jurkovicová O, Cagán S. Reperfúzne arytmie [Reperfusion arrhythmias]. Bratisl Lek Listy. 1998 Mar-Apr;99(3-4):162-71. Slovak. PMID: 9919746. Simmons T, Blazar E. Synergistic Bradycardia from Beta Blockers, Hyperkalemia, and Renal Failure. J Emerg Med. 2019 Aug;57(2):e41-e44. doi: 10.1016/j.jemermed.2019.03.039. Epub 2019 May 30. PMID: 31155316. Wung SF. Bradyarrhythmias: Clinical Presentation, Diagnosis, and Management. Crit Care Nurs Clin North Am. 2016 Sep;28(3):297-308. doi: 10.1016/j.cnc.2016.04.003. Epub 2016 Jun 22. PMID: 27484658. Summarized by Jeffrey Olson MS2 | Edited by Meg Joyce & Jorge Chalit, OMSII
Insulin EM Pulse PodcastThis is the next episode of our Push Dose Pearls miniseries with ED Pharmacist, Chris Adams. In this ongoing series we'll dig into some of the questions we all have about medications we commonly see and use in the ED. This episode again focuses on insulin. Should everyone with hyperglycemia get regular insulin? Is IV better than subcu? We'll answer these questions and more as we discuss the latest recommendations for managing hyperglycemia and DKA in the ED. Did this episode change your practice? Let us know on social media @empulsepodcast or at ucdavisem.com Hosts: Dr. Sarah Medeiros, Associate Professor of Emergency Medicine at UC Davis Dr. Julia Magaña, Associate Professor of Pediatric Emergency Medicine at UC Davis Guests: Christopher Adams, PharmD, Emergency Department Senior Clinical Pharmacist and Assistant Professor at UC Davis Resources: Hardern RD, Quinn ND Emergency management of diabetic ketoacidosis in adults Emergency Medicine Journal 2003;20:210-213 Schwartz X, Porter B, Gilbert MP, Sullivan A, Long B, Lentz S. Emergency Department Management of Uncomplicated Hyperglycemia in Patients without History of Diabetes. J Emerg Med. 2023 Aug;65(2):e81-e92. doi: 10.1016/j.jemermed.2023.04.018. Epub 2023 Apr 26. PMID: 37474343. *** Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Productions for audio production services.
Contributor: Meghan Hurley MD Educational Pearls: What do you do if you need a stat pregnancy test on an incapacitated patient? You can send a serum quantitative human chorionic gonadotropin (beta-HCG), but that might take a while for the lab to process. Another option is to place a drop of whole blood on a urine pregnancy immunoassay. These tests are already verified for urine and serum. 2012 study showed that whole blood was 95.8% sensitive for pregnancy compared to 95.3% for urine. Takes a little bit longer (10 minutes was used in the study) due to the viscosity of blood. Word of caution: This study only looked at a single urine pregnancy kit type. It is possible that other kits would have a different efficacy. There are new finger stick tests coming out for capillary blood. Anecdotally, Dr. Hurley was able to use this technique to support a diagnosis of ruptured ectopic pregnancy in a patient that needed emergent surgery. References Fromm C, Likourezos A, Haines L, Khan AN, Williams J, Berezow J. Substituting whole blood for urine in a bedside pregnancy test. J Emerg Med. 2012 Sep;43(3):478-82. doi: 10.1016/j.jemermed.2011.05.028. Epub 2011 Aug 27. PMID: 21875776. Sowder AM, Yarbrough ML, Nerenz RD, Mitsios JV, Mortensen R, Gronowski AM, Grenache DG. Analytical performance evaluation of the i-STAT Total β-human chorionic gonadotropin immunoassay. Clin Chim Acta. 2015 Jun 15;446:165-70. doi: 10.1016/j.cca.2015.04.025. Epub 2015 Apr 25. PMID: 25916696. Summarized by Jeffrey Olson, MS1 | Edited by Meg Joyce & Jorge Chalit, OMSII
References: Miles MVP, Beasley JR, Reed HE, Miles DT, Haiflich A, Beckett AR, Lee YL, Bowden SE, Panacek EA, Ding L, Brevard SB, Simmons JD, Butts CC. Overutilization of Helicopter Emergency Medical Services in Central Gulf Coast Region Results in Unnecessary Expenditure. J Surg Res. 2022 May;273:211-217. doi: 10.1016/j.jss.2021.12.038. Epub 2022 Jan 29. PMID: 35093837. Roman J, Shank W, Demirjian J, Tang A, Vercruysse GA. Overutilization of Helicopter Transport in the Minimally Burned-A Healthcare System Problem That Should Be Corrected. J Burn Care Res. 2020 Jan 30;41(1):15-22. doi: 10.1093/jbcr/irz143. PMID: 31504602. Adcock AK, Minardi J, Findley S, Daniels D, Large M, Power M. Value Utilization of Emergency Medical Services Air Transport in Acute Ischemic Stroke. J Emerg Med. 2020 Nov;59(5):687-692. doi: 10.1016/j.jemermed.2020.08.005. Epub 2020 Oct 1. PMID: 33011044; PMCID: PMC8006070. Chen X, Gestring ML, Rosengart MR, Peitzman AB, Billiar TR, Sperry JL, Brown JB. Logistics of air medical transport: When and where does helicopter transport reduce prehospital time for trauma? J Trauma Acute Care Surg. 2018 Jul;85(1):174-181. doi: 10.1097/TA.0000000000001935. PMID: 29787553. Chen X, Gestring ML, Rosengart MR, Billiar TR, Peitzman AB, Sperry JL, Brown JB. Speed is not everything: Identifying patients who may benefit from helicopter transport despite faster ground transport. J Trauma Acute Care Surg. 2018 Apr;84(4):549-557. doi: 10.1097/TA.0000000000001769. PMID: 29251708.
Welcome to Episode 25 of “The 2 View,” the podcast for EM and urgent care nurse practitioners and physician assistants! Show Notes for Episode 25 of “The 2 View” Pediatric Nurse Practitioners Are Not Okay Della Volpe K. We Are Not Ok, Say Pediatric NPs. Clinical Advisor. Published March 17, 2023. Accessed March 27, 2023. https://www.clinicaladvisor.com/home/meeting-coverage/napnap-2023/pediatric-nps-not-ok/?utmsource=newsletter&utmmedium=email&utmcampaign=NWLTRCADCONFNAPNAPMODERNA032023RM&hmEmail=1f%2FJfEV7hN5vJr6vg%2FQRqK0NA6IXtyO3&sha256email=092493d8223fdfa40d9e995176d13e5fc5b5211674db9deb440c025fd462c80c&hmSubId=&NID=1639413404&elqTrackId=31abe541d69a4ca587368d18c07e2aeb&elq=24134fa5abd64addafddd14ad54e8f8d&elqaid=13088&elqat=1&elqCampaignId=10964&fbclid=IwAR2YZErTgA9ET7Yzib3bPYuhD68VDtGAayIfQ2bu398LBTX6xEmLjZX3EY Sarjoo A. Pediatricians: We Can't Bear the Burden of Teen Angst. Medscape. Published March 13, 2023. Accessed March 27, 2023. https://www.medscape.com/viewarticle/989552 New TASER Bleetman A, Hepper AE, Sheridan RD. The use of TASER devices in UK policing: an update for clinicians following the recent introduction of the TASER 7. BMJ Journals. Emerg Med J. Published 2023. Accessed March 27, 2023. https://emj.bmj.com/content/40/2/147.long Taser Injuries. Emergency Central. Unboundmedicine.com. Accessed March 27, 2023. https://emergency.unboundmedicine.com/emergency/view/5-MinuteEmergencyConsult/307682/all/Taser_Injuries Vilke G, Chan T, Bozeman WP, Childers R. Emergency Department Evaluation After Conducted Energy Weapon Use: Review of the Literature for the Clinician. NIH National Library of Medicine: National Center for Biotechnology Information. PubMed. J Emerg Med. Published September 26, 2019. Accessed March 27, 2023. https://pubmed.ncbi.nlm.nih.gov/31500994/ Hyperacute T-Waves Dr. Smith's ECG blog. Blogspot.com. Published March 2023. Accessed March 27, 2023. http://hqmeded-ecg.blogspot.com/search/label/hyperacute%20T-waves Koechlin L, Strebel I, Zimmermann T, et al. Hyperacute T Wave in the Early Diagnosis of Acute Myocardial Infarction. Ann Emerg Med. PubMed. NIH: National Library of Medicine. National Center for Biotechnology Information. Published online February 9, 2023. Accessed March 27, 2023. https://pubmed.ncbi.nlm.nih.gov/36774205/ Writing Committee, Kontos MC, de Lemos JA, et al. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. Published November 2022. Accessed March 27, 2023. https://www.jacc.org/doi/10.1016/j.jacc.2022.08.750 DEA Updates – Segment with Dr. Rick Bukata Criteria for Furnishing Number Utilization by Nurse Practitioners. State of California, DCA (Department of Consumer Affairs). Board of Registered Nursing. Rn.ca.gov. Accessed March 27, 2023. https://www.rn.ca.gov/pdfs/regulations/npr-i-16.pdf DEA Announces Proposed Rules for Permanent Telemedicine Flexibilities. Drug Enforcement Administration (DEA). Published February 24, 2023. Accessed March 27, 2023. https://www.dea.gov/press-releases/2023/02/24/dea-announces-proposed-rules-permanent-telemedicine-flexibilities Mid-Level Practitioners Authorization by State. US Department of Justice. Drug Enforcement Administration. Diversion Control Division. Usdoj.gov. Accessed March 27, 2023. https://www.deadiversion.usdoj.gov/drugreg/practioners/ Removal of DATA Waiver (X-Waiver) Requirement. SAMHSA. Substance Abuse and Mental Health Services Administration. Samhsa.gov. Last Updated January 25, 2023. Accessed March 27, 2023. https://www.samhsa.gov/medications-substance-use-disorders/removal-data-waiver-requirement Statutory Changes in Pharmacy Law. Pharmacy.ca.gov. Published December 9, 2022. Accessed March 27, 2023. https://www.pharmacy.ca.gov/lawsregs/newlaws.pdf Recurring Sources Center for Medical Education. Ccme.org. http://ccme.org The Proceduralist. Theproceduralist.org. http://www.theproceduralist.org The Procedural Pause. Emergency Medicine News. Lww.com. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx The Skeptics Guide to Emergency Medicine. Thesgem.com. http://www.thesgem.com Trivia Question: Send answers to 2viewcast@gmail.com Be sure to keep tuning in for more great prizes and fun trivia questions! Once you hear the question, please email us your guesses at 2viewcast@gmail.com and tell us who you want to give a shout-out to. Be sure to listen in and see what we have to share!
Apologies for being MIA for a month now. Been busy! But am back and in this episode talk about calcium channel blocker toxicity. The physiology behind it, a little pharmacology and then the treatment. Busting some myths and reinforcing the need for proactive emergency medicine evidence based treatment. You can check out these papers and do more research for yourselves too - 1. Wightman RSHRA. Cardiologic Principles II: Hemodynamics. In: Nelson LS, Howland MA, Lewin NA, et al, editors. Goldfrank's toxicologic emergencies. 11th Edition. New York City, NY: McGraw Hill; 2019. p. 260–7 2. Levine M, Brent. Beta-Receptor Antagonists. In: Brent J, Burkhart K, Daragan P, et al, editors. Critical care toxicology. New York City, NY: Mosby; 2017. p. 771–86. Wallukat G. The beta-adrenergic receptors. Herz 2002;27(7):683–90. 4. Ranniger C, Roche C. Are one or two dangerous? Calcium channel blocker exposure in toddlers. J Emerg Med 2007;33(2):145–54 5. Gummin DD, Mowry JB, Beuhler MC, et al. 2019 Annual Report of the American Association of Poison Control Centers' National Poison Data System (NPDS): 37th Annual Report. Clin Toxicol 2020;58(12):1360–541. 6. Holger JS, Engebretsen KM, Obetz CL, et al. A comparison of vasopressin and glucagon in beta-blocker induced toxicity. Clin Toxicol 2006;44(1):45–51 7. Jang DH, Donovan S, Nelson LS, et al. Efficacy of methylene blue in an experimental model of calcium channel blocker-induced shock. Ann Emerg Med 2015;65(4):410–5. 8. Laes JR, Williams DM, Cole JB. Improvement in hemodynamics after methylene blue administration in drug-induced vasodilatory shock: a case report. J Med Toxicol 2015;11(4):460–3. 9. Wang GS, Levitan R, Wiegand TJ, et al. Extracorporeal membrane oxygenation (ECMO) for severe toxicological exposures: review of the toxicology investigators consortium (ToxIC). J Med Toxicol 2016;12(1):95–9 10. Hayes BD, Gosselin S, Calello DP, et al. Systematic review of clinical adverse events reported after acute intravenous lipid emulsion administration. Clin Toxicol 2016;54(5):365–404 11. American College of Medical Toxicology. ACMT position statement: guidance for the use of intravenous lipid emulsion. J Med Toxicol 2017;13(1):124–5. 12. Kerns W 2nd. Management of beta-adrenergic blocker and calcium channel antagonist toxicity. Emerg Med Clin North Am. 2007 May;25(2):309-31; abstract viii. doi: 10.1016/j.emc.2007.02.001. PMID: 17482022. 13. Cole JB, Arens AM. Cardiotoxic Medication Poisoning. Emerg Med Clin North Am. 2022 May;40(2):395-416. doi: 10.1016/j.emc.2022.01.014. Epub 2022 Apr 5. PMID: 35461630.
In the first episode of this season I talk about using high dose Nitroglycerine and Bipap for the sympathetic crashing acute pulmonary edema (SCAPE) patients in you ED. Don't take my word for it. Go through the following references and make your own protocol for your department. We have had fantastic results! 1. Paone S, Clarkson L, Sin B, Punnapuzha S. Recognition of Sympathetic Crashing Acute Pulmonary Edema (SCAPE) and use of high-dose nitroglycerin infusion. Am J Emerg Med. 2018 Aug;36(8):1526.e5-1526.e7. doi: 10.1016/j.ajem.2018.05.013. Epub 2018 May 10. PMID: 29776826. 2. Mathew R, Kumar A, Sahu A, Wali S, Aggarwal P. High-Dose Nitroglycerin Bolus for Sympathetic Crashing Acute Pulmonary Edema: A Prospective Observational Pilot Study. J Emerg Med. 2021 Sep;61(3):271-277. doi: 10.1016/j.jemermed.2021.05.011. Epub 2021 Jun 30. PMID: 34215472. 3.Hsieh YT, Lee TY, Kao JS, Hsu HL, Chong CF. Treating acute hypertensive cardiogenic pulmonary edema with high-dose nitroglycerin. Turk J Emerg Med. 2018 Feb 2;18(1):34-36. doi: 10.1016/j.tjem.2018.01.004. PMID: 29942881; PMCID: PMC6009803. 4. Levy P, Compton S, Welch R, Delgado G, Jennett A, Penugonda N, Dunne R, Zalenski R. Treatment of severe decompensated heart failure with high-dose intravenous nitroglycerin: a feasibility and outcome analysis. Ann Emerg Med. 2007 Aug;50(2):144-52. doi: 10.1016/j.annemergmed.2007.02.022. Epub 2007 May 23. PMID: 17509731. 5.Houseman BS, Martinelli AN, Oliver WD, Devabhakthuni S, Mattu A. High-dose nitroglycerin infusion description of safety and efficacy in sympathetic crashing acute pulmonary edema: The HI-DOSE SCAPE study. Am J Emerg Med. 2023 Jan;63:74-78. doi: 10.1016/j.ajem.2022.10.018. Epub 2022 Oct 18. PMID: 36327753.
Dr. Ben Sandefur, Emergency Medicine attending at Mayo Clinic, joins Alex and Venk on the podcast to talk about angioedema and awake tracheal intubation. He reviews the different types of angioedema in a format designed to assist the emergency department practitioner with decision making and prognostication. This is followed by a description of how to prepare for and lead a team and patient through awake tracheal intubation using fiberoptic and video laryngoscopy techniques. Contacts TWITTER - @AlwaysOnEM; @VenkBellamkonda INSTAGRAM – @AlwaysOnEM; @Venk_like_vancomycin; @ASFinch EMAIL - AlwaysOnEM@gmail.com References Rosenbaum S, Wilkerson RG, Winters ME, Vilke GM, Wu MYC. Clinical Practice Statement: What is the Emergency Department Management of Patients with Angioedema Secondary to an ACE-Inhibitor? J Emerg Med. 2021 Jul;61(1):105-112 [from the American Academy of Emergency Medicine] https://pubmed.ncbi.nlm.nih.gov/34006418/ Moellman JJ, Bernstein JA, et al. A consensus parameter for the evaluation and management of angioedema in the emergency department. Acad Emerg Med. 2014 Apr;21(4):469-84 [from the American College of Allergy, Asthma & Immunology (ACAAI) and the Society for Academic Emergency Medicine (SAEM)] https://pubmed.ncbi.nlm.nih.gov/24730413/ Carrillo-Martin I, Gonzalez-Estrada A, Funni SA, Sandefur BJ, Jeffery MM, Campbell RL. Angioedema - related emergency department visits in the United States: Epidemiology and time trends, 2006-2015. J Allergy Clin Immunol Pract. 2020 Jul-Aug;8(7):2442-2444. https://pubmed.ncbi.nlm.nih.gov/32302784/ Ishoo E, Shah UK, Grillone GA, Stram JR, Fuleihan NS. Predicting airway risk in angioedema: staging system based on presentation. Otolaryngol Head Neck Surg. 1999 Sep;121(3):263-8 https://pubmed.ncbi.nlm.nih.gov/10471868/ Arthur J, Caro D, Topp S, Chadwick S, Driver B, Henson M, Norse A, Spencer H, Godwin SA, Guirgis F. Clinical predictors of endotracheal intubation in patients presenting to the emergency department with angioedema. Am J Emerg Med. 2022 Oct 19;63:44-49 https://pubmed.ncbi.nlm.nih.gov/36327748/ Sandefur BJ, Liu XW, Kaji AH, Campbell RL, Driver BE, Walls RM, Carlson JN, Brown CA. Emergency Department Intubations in Patients with Angioedema: A Report from the National Emergency Airway Registry. J Emerg Med. 2021 Nov;61(5):481-488 https://pubmed.ncbi.nlm.nih.gov/34479750/ Sandefur BJ, Oliveira Silva L, Lohse CM, Goyal KA, Barbara DW, Castaneda-Guarderas A, Liu XW, Campbell RL. Clinical features and outcomes associated with angioedema in the emergency department. West J Emerg Med. 2019 Aug 6;20(5):760-769 https://pubmed.ncbi.nlm.nih.gov/31539333/ Additional Resources Wilkerson RG, Moellman JJ. Hereditary Angioedema. Emerg Med Clin North Am. 2022 Feb;40(1):99-118 https://pubmed.ncbi.nlm.nih.gov/34782094/ Wilkerson RG, Winters ME. Angiotensin-Converting Enzyme Inhibitor-Induced Angioedema. Emerg Med Clin North Am. 2022 Feb;40(1):79-98 https://pubmed.ncbi.nlm.nih.gov/34782093/
Contributor: Travis Barlock, MD Educational Pearls: The presence of a STEMI has traditionally been used to determine if a patient with acute chest pain requires urgent cath lab management STEMI indicates an occluded coronary artery, and urgent intervention is needed to restore perfusion to ischemic tissue Patients with occluded coronary arteries can present with EKG findings other than STEMI 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department was recently published in the Journal of the American College of Cardiology Recognizes STEMI equivalents that necessitate cath lab management ST depression in precordial leads Indicates a posterior infarct/possible RCA occlusion LBBB c ST elevation meeting modified Sgarbossa criteria Hyperacute and/or De Winter T wave First indication of coronary artery occlusion Most beneficial time to initiate cath lab because more tissue is salvageable These recommendations will likely alter clinical practice for ED management of acute chest pain References Kontos MC, de Lemos JA, Deitelzweig SB, et al. 2022 ACC Expert Consensus Decision Pathway on the Evaluation and Disposition of Acute Chest Pain in the Emergency Department: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. Oct 6 2022;doi:10.1016/j.jacc.2022.08.750 Meyers HP, Bracey A, Lee D, et al. Comparison of the ST-Elevation Myocardial Infarction (STEMI) vs. NSTEMI and Occlusion MI (OMI) vs. NOMI Paradigms of Acute MI. J Emerg Med. Mar 2021;60(3):273-284. doi:10.1016/j.jemermed.2020.10.026 Tziakas D, Chalikias G, Al-Lamee R, Kaski JC. Total coronary occlusion in non ST elevation myocardial infarction: Time to change our practice? Int J Cardiol. Apr 15 2021;329:1-8. doi:10.1016/j.ijcard.2020.12.082 Summarized by Mark O'Brien, MS4 | Edited by John Spartz, MD, & Erik Verzemnieks, MD In an effort to promote diversity, equity, and inclusion in Emergency Medicine, The Emergency Medical Minute is proud to present our 2nd annual Diversity and Inclusion Award. We support increasing the representation of underrepresented groups in medicine and extend this award to individuals applying to emergency medicine residencies during the 2022-2023 cycle. For information on award eligibility and the application process, visit https://emergencymedicalminute.com/edi-award/ Donate to EMM today!
Join our Emergency General Surgery team as they discuss Necrotizing Soft-Tissue Infections. Hosted by Drs. Jordan Nantais, Ashlie Nadler, Stephanie Mason and Graham Skelhorne-Gross. Necrotizing Soft-Tissue Infections: - Also known as “flesh eating disease”, gas gangrene, necrotizing fasciitis/myositis, Fournier's gangrene. - Early findings are non-specific - Rapidly fatal - diagnostic delay can lead to tremendous additional morbidity and mortality Classification: - Type 1 - polymicrobial category (most common) found in immunosuppressed or elderly - Type 2 - monomicrobial infection [Group A Streptococcus > Methicillin-resistant Staphylococcus aureus (MRSA)] - Type 3 - monomicrobial infection (Vibrio or Clostridium) - Type 4 - fungal (rare) in immunocompromised or after penetration or trauma from candida or Zygomycetes. Initial Workup - History: (comorbidities, immunosuppression, recent infections or trauma) - Exam: swelling, open lesions, drainage, erythema, crepitus, and pain out of proportion - Most common: swelling, pain, erythema - Bullae, skin necrosis, crepitus are less common - Labs: Hb, wbc, Na, Creat, glucose, and CRP - Imaging: CT, MRI *sensitive and specific but may not change management - Cut-down: bedside vs in OR - Gm stain Management - Initially: two large bore IVs, foley catheter, aggressive fluid resuscitation, broad spectrum antibiotics, vasopressors PRN - Abx choices: carbopenem or piperacllin-tazobactam or cefotaxime plus metronidazole. Clindamycin (antitoxin effect) and vancomycin (MRSA) should be considered. - OR: must debride all dead/infected tissue, involve other surgical specialties as needed - Mark edge of cellulitis and use as initial debridement - Healthy dermis – pearly and white - Healthy fat – pale, yellow, glistening - Healthy fascia – should bleed, doesn't easily separate from muscle - Healthy muscle – contract with cautery - Dressing: betadine-soaked gauze on the wound - Most patients will need at least 3 ORs (second OR generally 8-12 hours after the first) - No VAC or stoma at first OR References: 1. Pelletier J, Gottlieb M, Long B, Perkins JC Jr. Necrotizing Soft Tissue Infections (NSTI): Pearls and Pitfalls for the Emergency Clinician. J Emerg Med. 2022 Apr;62(4):480-491. doi: 10.1016/j.jemermed.2021.12.012. Epub 2022 Jan 31. 2. Sarani B, Strong M, Pascual J, Schwab CW. Necrotizing fasciitis: current concepts and review of the literature. J Am Coll Surg. 2009 Feb;208(2):279-88. 3. Edlich RF, Cross CL, Dahlstrom JJ, Long WB 3rd. Modern concepts of the diagnosis and treatment of necrotizing fasciitis. J Emerg Med. 2010 Aug;39(2):261-5 4. Hoesl V, Kempa S, Prantl L, Ochsenbauer K, Hoesl J, Kehrer A, Bosselmann T. The LRINEC Score-An Indicator for the Course and Prognosis of Necrotizing Fasciitis? J Clin Med. 2022 Jun 22;11(13):3583 5. Bulger EM, May A, Bernard A, Cohn S, Evans DC, Henry S, Quick J, Kobayashi L, Foster K, Duane TM, Sawyer RG, Kellum JA, Maung A, Maislin G, Smith DD, Segalovich I, Dankner W, Shirvan A. Impact and Progression of Organ Dysfunction in Patients with Necrotizing Soft Tissue Infections: A Multicenter Study. Surg Infect (Larchmt). 2015 Dec;16(6):694-701. 6. LRINEC Score from: https://www.mdcalc.com/calc/1734/lrinec-score-necrotizing-soft-tissue-infection#:~:text=Patients%20were%20classified%20into%20three,%25%20and%20NPV%20of%2096%25. Retrieved July 2022. If you liked this episode, check out our recent episode titled, "Journal Review in Colorectal Surgery: Timing of Biologics and Surgery in the Setting of Crohn's Disease" which can be found here. Please visit behindtheknife.org to access other high-yield surgical education podcasts, videos and more.
Integrating an ED clinical pharmacist was a complete practice changer for us at UC Davis! It is a positive trend across the US and in this episode, we talk with Chris Adams, Clinical Senior Pharmacist at UC Davis. Tell us how YOUR department integrates a pharmacist @empulsepodcast, or reach out via email empulsepodcast@gmail.com, or through our website, ucdavisem.com. Encourage your friends and colleagues to listen and share their stories, too! ***Please rate us and leave us a review on iTunes! It helps us reach more people.*** Host: Dr. Julia Magaña, Associate Professor of Pediatric Emergency Medicine at UC Davis Guest: Chris Adams, Clinical Senior Pharmacist at UC Davis *** Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Audio Productions for audio production services. Resources: Farmer BM, Hayes BD, Rao R, Farrell N, Nelson L. The role of clinical pharmacists in the emergency department. J Med Toxicol. 2018;14(1):114-116. Acquisto NM, Hays DP, Fairbanks RJT, et al. The outcomes of emergency pharmacist participation during acute myocardial infarction. J Emerg Med. 2012;42(4):371-378. Jacoby JS, Draper HM, Dumkow LE, Farooq MU, DeYoung GR, Brandt KL. Emergency medicine pharmacist impact on door-to-needle time in patients with acute ischemic stroke. Neurohospitalist. 2018;8(2):60-65. Moussavi K, Nikitenko V. Pharmacist impact on time to antibiotic administration in patients with sepsis in an ED. Am J Emerg Med. 2016;34(11):2117-2121. Patanwala AE, Sanders AB, Thomas MC, et al. A prospective, multicenter study of pharmacist activities resulting in medication error interception in the emergency department. Ann Emerg Med. 2012;59(5):369-373.
Contributor: Aaron Lessen, MD Educational Pearls: Hyperglycemic Hyperosmolar State (HHS) is less common than Diabetic Ketoacidosis (DKA) but is associated with a mortality rate up to 10 times greater than that seen in DKA Typically seen in elderly patients with severely elevated blood glucose levels (>1000 mg/dL) and an increased plasma osmolality Unlike in DKA, patients with HHS do not have elevated ketones Treatment of HHS includes insulin administration along with correcting fluid and electrolyte abnormalities When treating HHS, it is important to monitor and follow osmolality regularly because over-rapid correction can result in the development of cerebral edema References Fayfman M, Pasquel FJ, Umpierrez GE. Management of Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. Med Clin North Am. 2017;101(3):587-606. Gosmanov AR, Gosmanova EO, Kitabchi AE. Hyperglycemic Crises: Diabetic Ketoacidosis and Hyperglycemic Hyperosmolar State. In: Feingold KR, Anawalt B, Boyce A, et al., eds. Endotext. South Dartmouth (MA): MDText.com, Inc. Copyright © 2000-2022, MDText.com, Inc.; 2000. Long B, Willis GC, Lentz S, Koyfman A, Gottlieb M. Diagnosis and Management of the Critically Ill Adult Patient with Hyperglycemic Hyperosmolar State. J Emerg Med. 2021;61(4):365-375. Summarized by Mark O'Brien, MS4 | Edited by John Spartz MS4 & Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!
Date: May 13th, 2022 Reference: Abril et al. The Relative Efficacy of Seven Skeletal Muscle Relaxants. An Analysis of Data From Randomized Studies. J Emerg Med 2022 Guest Skeptic: Dr. Sergey Motov is an Emergency Physician in the Department of Emergency Medicine, Maimonides Medical Center in New York City. He is also one of the world's leading […]
Contributor: Ricky Dhaliwal, MD Educational Pearls: Esophageal food impaction can be managed in the ED prior to calling GI for endoscopy Coca-cola, glucagon, benzodiazepines, calcium channel blockers, and dissolved nitroglycerin are all options to try For pediatric patients, weighted bougies can be used under sedation to attempt retrieval of the food bolus Always evaluate airway status, especially if the patient cannot maintain secretions References Long B, Koyfman A, Gottlieb M. Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-Based Review. J Emerg Med. 2019;56(5):499-511. doi:10.1016/j.jemermed.2019.01.025 Khayyat YM. Pharmacological management of esophageal food bolus impaction. Emerg Med Int. 2013;2013:924015. doi:10.1155/2013/924015 Schimmel J, Slauson S. Swallowed Nitroglycerin to Treat Esophageal Food Impaction. Ann Emerg Med. 2019;74(3):462-463. doi:10.1016/j.annemergmed.2019.04.003 Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at https://emergencymedicalminute.org/cme-courses/ and create an account. Donate to EMM today!
If you're an emergency physician, or have goals of becoming one, you have probably heard about ACEP's workforce study. The findings first came out in April 2021, and were followed by a full paper in Annals of Emergency Medicine in August. The bottom line is that there is a predicted surplus of EM physicians of over 7,800 by 2030. How did we find ourselves here? What does this mean? And what should we do about it? We reached out to Emergency Physician and ACEP President Elect, Dr. Gillian Schmitz, to learn more. What was your reaction to the workforce report? What do you think is the path forward for our specialty? Connect with us on social media, @empulsepodcast, or through our website, ucdavisem.com. ***Please rate us and leave us a review on iTunes! It helps us reach more people.*** Hosts: Dr. Julia Magaña, Associate Professor of Pediatric Emergency Medicine at UC Davis Dr. Sarah Medeiros, Associate Professor of Emergency Medicine at UC Davis Guest: Dr. Gillian Schmitz, ACEP President Elect, Associate Professor of Emergency Medicine at the Uniformed Services University of Health Sciences, Emergency Physician at Brooke Army Medical Center Resources: ACEP EM Physician Workforce of the Future Reiter M, Allen BW. The Emergency Medicine Workforce: Shortage Resolving, Future Surplus Expected. J Emerg Med. 2020 Feb;58(2):198-202. doi: 10.1016/j.jemermed.2020.01.004. Epub 2020 Apr 3. *** Thank you to the UC Davis Department of Emergency Medicine for supporting this podcast and to Orlando Magaña at OM Audio Productions for audio production services.
Addendums on the calcium episode and the heart failure episode...as always...random ramblings as well... Citations: Anand IS, Gupta P. Anemia and Iron Deficiency in Heart Failure: Current Concepts and Emerging Therapies. Circulation. 2018 Jul 3;138(1):80-98. doi: 10.1161/CIRCULATIONAHA.118.030099. PMID: 29967232. Hayes. (2013). Mythbuster: Calcium Gluconate Raises Serum Calcium as Quickly as Calcium Chloride. Retrieved at https://www.aliem.com/mythbuster-calcium-gluconate-raises-serum-calcium-as-calcium-chloride/ Calcium Chloride. RK.MD Blog. (2018). Retrieved at https://rk.md/2018/calcium-chloride/ Maak CA, Tabas JA, McClintock DE. Should acute treatment with inhaled beta agonists be withheld from patients with dyspnea who may have heart failure? J Emerg Med. 2011 Feb;40(2):135-45. doi: 10.1016/j.jemermed.2007.11.056. Epub 2008 Jun 24. PMID: 18572345. Ponn, B. (2017). Clinical Question: Can Ventolin improve wheeze in heart failure? CanadiEM Blog. Retrieved from https://canadiem.org/can-ventolin-improve-wheeze-in-heart-failure/ Silverberg DS, Wexler D, Iaina A. The role of anemia in the progression of congestive heart failure. Is there a place for erythropoietin and intravenous iron? J Nephrol. 2004 Nov-Dec;17(6):749-61. PMID: 15593047. This podcast is hosted by ZenCast.fm
SummaryExposure to warm environments can cause a number of heat-related illnesses including muscle cramps, heat rash, edema, syncope, heat exhaustion, and heat stroke. All of these issues are preventable. Early recognition of heat stroke is paramount for improving survival. Cool patients with cold water immersion. Morbidity and MortalityApproximately 600 deaths occur every year in the United States related to heat. It is a leading cause of death in high school athletes. Mortality from heat stroke approaches 10% even in modern times. StoryAs many as 53 children die every year from heat related vehicle entrapment in the United States. Most of these cases are due to people forgetting the child was in the car. The second leading cause is children getting into unattended cars. Always know where your baby or child is and keep your unattended car locked. A record-breaking heat wave in Europe in 2003 killed at least 30,000 people, mostly elderly. Taking cool baths throughout the day could have prevented many of these deaths. Key Points1. Risk factors for heat illness include older age, dehydration, impaired cooling capacity, lack of acclimatization, poor fitness, lack of sleep, chronic health issues, and obesity. 2. Temperature, wind, humidity, and solar radiation all effect the thermal strain felt by any individual.3. Heat exhaustion is common and characterized by fatigue, thirst, weakness, anxiety, and dizziness. Heat stroke is much more severe and can be distinguished from exhaustion by the presence of altered coordination, balance, and/or mentation. 4. Rapid cooling is the most important treatment for heat stroke. Cold water emersion is the gold standard for lowering body temperature. References- Lipman et al. WMS Practice Guidelines for the Prevention and Treatment of Heat-Related Illness. Wild & Env Med. 2014.- O'Brien et al. Clinical Management of Heat-Related Illnesses. Ch. 13. Auerbachs, Wilderness Medicine. - Gaudio FG, Grissom CK. Cooling Methods in Heat Stroke. J Emerg Med. 2016- Wikipedia – Heat Stroke- Personal experience as a physician and athlete
Contributor: Ricky Dhaliwal, MD Educational Pearls: Hypotension in patients requiring intubation should be resuscitated as much as possible While intubating, the negative inspiratory pressure goes away decreasing cardiac preload and worsening hypotension Phenylephrine can be given via push doses to increase blood pressure from alpha agonism For sedation, avoid propofol with hypotension and opt for etomidate or ketamine References April MD, Arana A, Schauer SG, et al. Ketamine Versus Etomidate and Peri-intubation Hypotension: A National Emergency Airway Registry Study. Acad Emerg Med. 2020;27(11):1106-1115. doi:10.1111/acem.14063 Panchal AR, Satyanarayan A, Bahadir JD, Hays D, Mosier J. Efficacy of Bolus-dose Phenylephrine for Peri-intubation Hypotension. J Emerg Med. 2015;49(4):488-494. doi:10.1016/j.jemermed.2015.04.033 Jaber S, Amraoui J, Lefrant JY, et al. Clinical practice and risk factors for immediate complications of endotracheal intubation in the intensive care unit: a prospective, multi-center study. Crit Care Med. 2006;34:2355–61. Summarized by John Spartz, MS4 | Edited by Erik Verzemnieks, MD *********************
In Folge 27 haben wir ein Interview über Aggressionsmanagement geführt und da bei den meisten Aggressionsereignissen bekanntlich Alkohol mit im Spiel ist, erklärt uns Marius alles wissenswerte über den Blutalkoholspiegel. · Alkoholrechner von blick.ch: https://storytelling.blick.ch/infografik/2017/alkrechner · Lippi G, Simundic AM, Musile G, Danese E, Salvagno G, Tagliaro F. The alcohol used for cleansing the venipuncture site does not jeopardize blood and plasma alcohol measurement with head-space gas chromatography and an enzymatic assay. Biochem Med (Zagreb). 2017 Jun 15;27(2):398-403. doi: 10.11613/BM.2017.041. PMID: 28694729; PMCID: PMC5493181. · McIvor RA, Cosbey SH: Effect of using alcoholic and non-alcoholic skin cleansing swabs when sampling blood for alcohol estimation using gas chromatography. Br J Clin Pract. 1990 Jun;44(6):235-6. · Miller MA, Rosin A, Levsky ME, Gregory TJ, Crystal CS: Isopropyl alcohol pad use for blood ethanol sampling does not cause false-positive results. J Emerg Med. 2007 Jul;33(1):9-10. · https://www.synlab.ch/docs/default-source/labolink/alkoholkonsum-(ethanol)-und-die-m%C3%B6glichkeiten.pdf?sfvrsn=9f22aa38_0 · https://ladr.de/diagnostik/a-z-suche?verz_id=491&weiterleitung=Phosphatidylethanol
For Paramedics, click here for CEU credits! They're not little adults nor are they little aliens... They're just kids. Pediatric Out of Hospital Cardiac Arrest (p-OHCA) is a terrifying case for any health care clinician. In this two-part series, the But Why EMS Podcast team covers the evidence behind p-OHCA and the growing push to resuscitate on the scene with special guest John Graham MD Pediatric Emergency Medicine Physician Fellow. Click here to check out the episode today! Also, check out our sister podcast The Prehospital Emergency Care Podcast's February episode discussing the utility of Pediatric intraosseous needles in p-OHCA! Thank you for listening! Hawnwan Philip Moy MD Gina Pellerito EMT-P John Reagan EMT-P Works Cited “Monty Python - "Not Dead Yet" Scene (HD)” YouTube, Downloaded by Phil Moy February 19, 2021. https://www.youtube.com/watch?v=Jdf5EXo6I68&t=2s&ab_channel=Browningate Dreams Become Real by Kevin MacLeod is licensed under a Creative Commons Attribution 4.0 license. https://creativecommons.org/licenses/by/4.0/ Source: http://incompetech.com/music/royalty-free/index.html?isrc=USUAN1500027 Artist: http://incompetech.com/ Eternal Hope by Kevin MacLeod is licensed under a Creative Commons Attribution 4.0 license. https://creativecommons.org/licenses/by/4.0/ Source: http://incompetech.com/music/royalty-free/index.html?isrc=USUAN1100238 Artist: http://incompetech.com/ Eastin C, Karim S, Hawthorn C, Webb MH, Waheed MA, Buford A, Hutchison M, Mason C, Sexton K. Mandated 30-minute Scene Time Interval Correlates With Improved Return of Spontaneous Circulation at Emergency Department Arrival: A Before and After Study. J Emerg Med. 2019 Oct;57(4):527-534. doi: 10.1016/j.jemermed.2019.06.021. Epub 2019 Aug 28. PMID: 31472942. Banerjee PR, Ganti L, Pepe PE, Singh A, Roka A, Vittone RA. Early On-Scene Management of Pediatric Out-of-Hospital Cardiac Arrest Can Result in Improved Likelihood for Neurologically-Intact Survival. Resuscitation. 2019 Feb;135:162-167. doi: 10.1016/j.resuscitation.2018.11.002. Epub 2018 Nov 6. PMID: 30412719. Grunau B, Kime N, Leroux B, et al. Association of Intra-arrest Transport vs Continued On-Scene Resuscitation With Survival to Hospital Discharge Among Patients With Out-of-Hospital Cardiac Arrest. JAMA. 2020;324(11):1058–1067. doi:10.1001/jama.2020.14185. Broughton W, Paediatric cardiac arrest: time to ‘stay and play’? Journal of Paramedic Practice. 2015 Dec. https://www.paramedicpractice.com/features/article/paediatric-cardiac-arrest-time-to-stay-and-play
The Podcasts of the Royal New Zealand College of Urgent Care
Are you familiar with this way of managing dermal avulsion injuries? Check out the original paper describing this technique A novel, simple method for achieving haemostasis of fingertip dermal avulsion injuries. Brian Lin. J Emerg Med 2015 Jun;48(6):702-5 https://pubmed.ncbi.nlm.nih.gov/25886984/ Also, check out Dr Lin's piece here at the Academic Life in Emergency Medicine blog. https://www.aliem.com/trick-of-trade-dermal-avulsion-injuries-2-0/ www.rnzcuc.org.nz podcast@rnzcuc.org.nz https://www.facebook.com/rnzcuc https://twitter.com/rnzcuc Music licensed from www.premiumbeat.com Full Grip by Score Squad This podcast is intended to assist in ongoing medical education and peer discussion for qualified health professionals. Please ensure you work within your scope of practice at all times. For personal medical advice always consult your usual doctor
View the show notes in Google Docs here: http://bit.ly/3bFS43j Gonorrhea Updates Gonorrhea Treatment and Care. Centers for Disease Control and Prevention Website. https://www.cdc.gov/std/gonorrhea/treatment.htm. Published December 14, 2020. Accessed January 11, 2021. CDC No Longer Recommends Oral Drug for Gonorrhea Treatment. Centers for Disease Control and Prevention. https://www.cdc.gov/nchhstp/newsroom/2012/gctx-guidelines-pressrelease.html. Published August 9, 2012. Accessed January 11, 2021. Recurrent UTI Recurrent Uncomplicated Urinary Tract Infections in Women: AUA/CUA/SUFU Guideline (2019). American Urological Association. https://www.auanet.org/guidelines/recurrent-uti?fbclid=IwAR1TwSTQNHv8PDWLfW7WjsDan46D_9b6Qs1ptJxaXr6YFnDpBeptpW3BY. Published 2019. Accessed January 11, 2021. Combo Ibuprofen and Acetaminophen / Pain Advil® Dual Action. GSK Expert Portal. https://www.gskhealthpartner.com/en-us/pain-relief/brands/advil/products/dual-action/?utmsource=google&utmmedium=cpc&utmterm=ibuprofen+acetaminophen&utmcampaign=GS+-+Unbranded+Advil+DA+-+Alone+-+PH. Accessed January 11, 2021. FDA approves GSK's Advil Dual Action with Acetaminophen for over-the-counter use in the United States. GSK. https://www.gsk.com/en-gb/media/press-releases/fda-approves-gsk-s-advil-dual-action-with-acetaminophen-for-over-the-counter-use-in-the-united-states/. Published March 2, 2020. Accessed January 11, 2021. Tanner T, Aspley S, Munn A, Thomas T. The pharmacokinetic profile of a novel fixed-dose combination tablet of ibuprofen and paracetamol. BMC clinical pharmacology. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2906415/. Published July 5, 2010. Accessed January 11, 2021. Searle S, Muse D, Paluch E, et al. Efficacy and Safety of Single and Multiple Doses of a Fixed-dose Combination of Ibuprofen and Acetaminophen in the Treatment of Postsurgical Dental Pain: Results From 2 Phase 3, Randomized, Parallel-group, Double-blind, Placebo-controlled Studies. The Clinical journal of pain. https://pubmed.ncbi.nlm.nih.gov/32271183/. Published July 2020. Accessed January 11, 2021. 1000 mg versus 600/650 mg Acetaminophen for Pain or Fever: A Review of the Clinical Efficacy. National Center for Biotechnology Information. https://www.ncbi.nlm.nih.gov/books/NBK373467/. Published June 17, 2016. Accessed January 11, 2021. Motov S. Is There a Limit to the Analgesic Effect of Pain Medications? Medscape. https://www.medscape.com/viewarticle/574279. Published June 17, 2008. Accessed January 11, 2021. Motov, Sergey. Faculty Forum: A Practical Approach to Pain Management. YouTube. https://www.youtube.com/watch?v=lJSioPsGw3A. The Center for Medical Education. Published December 2, 2020. Accessed January 1, 2021. Wuhrman E, Cooney MF. Acute Pain: Assessment and Treatment. Medscape. https://www.medscape.com/viewarticle/735034_4. Published January 3, 2011. Accessed January 11, 2021. Social Pain Dewall CN, Macdonald G, Webster GD, et al. Acetaminophen reduces social pain: behavioral and neural evidence. Psychological science. https://pubmed.ncbi.nlm.nih.gov/20548058/. Published June 14, 2010. Accessed January 11, 2021. Mischkowski D, Crocker J, Way BM. From painkiller to empathy killer: acetaminophen (paracetamol) reduces empathy for pain. Social cognitive and affective neuroscience. https://pubmed.ncbi.nlm.nih.gov/27217114/. Published May 5, 2016. Accessed January 11, 2021. Other / Recurrent liner notes Center for Medical Education. https://courses.ccme.org/. Accessed January 11, 2021. Roberts M, Roberts JR. The Proceduralist. https://www.theproceduralist.org/. Accessed January 11, 2021. The Procedural Pause by James R. Roberts, MD, & Martha Roberts, ACNP, PNP. Emergency Medicine News. https://journals.lww.com/em-news/blog/theproceduralpause/pages/default.aspx. Accessed January 11, 2021. The Skeptics' Guide to Emergency Medicine. sgem.ccme.org. https://sgem.ccme.org/. Accessed January 11, 2021. Trivia Question: Send answers to 2viewcast@gmail.com Please note that you must answer the 2 part question to win a copy of the EMRA Pain Guide. “What controversial drug was given a black box warning for prolonged QT and torsades in 2012 and now has been declared by WHICH organization to be an effective and safe treatment use for nausea, vomiting, headache and agitation?” Practical Pain Management in Acute Care Setting Handout Sergey Motov, MD @painfreeED • Pain is one of the most common reasons for patients to visit the emergency department and other acute care settings. Due to the extensive number of visits related to pain, clinicians and midlevel providers should be aware of the various options, both pharmacological and nonpharmacological, available to treat patients with acute pain. • As the death toll from the opioid epidemic continues to grow, the use of opioids in the acute care setting as a first-line treatment for analgesia is becoming increasingly controversial and challenging. • There is a growing body of literature that is advocating for more judicious use of opioids and well as their prescribing and for broader use of non-pharmacological and non-opioid pain management strategies. • The channels/enzymes/receptors targeted analgesia (CERTA) concept is based on our improved understanding of the neurobiological aspect of pain with a shift from a symptom-based approach to pain to a mechanistic approach. This targeted analgesic approach allows for a broader utilization of synergistic combinations of nonopioid analgesia and more refined and judicious (rescue) use of opioids. These synergistic combinations result in greater analgesia, fewer side effects, lesser sedation, and shorter LOS. (Motov et al 2016) General Principles: Management of acute pain in the acute care setting should be patient-centered and pain syndrome-specific by using multimodal approach that include non-pharmacological modalities and pharmacological ones that include non-opioid and opioid analgesics. Assessment of acute pain should be based on a need for analgesics to improve functionality, rather than patients-reported pain scores. Brief pain inventory short form BPI-SF is better than NRS/VAS as it assesses quantitative and qualitative impact of pain (Im et al 2020). ED clinicians should engage patients in shared decision-making about overall treatment goals and expectations, the natural trajectory of the specific painful condition, and analgesic options including short-term and long-term benefits and risks of adverse effects. If acute pain lasting beyond the expected duration, complications of acute pain should be ruled out and transition to non-opioid therapy and non-pharmacological therapy should be attempted. Non-Pharmacologic Therapies • Acute care providers should consider applications of heat or cold as well as specific recommendations regarding activity and exercise. • Music therapy is a useful non-pharmacologic therapy for pain reduction in acute care setting (music-assisted relaxation, therapeutic listening/musical requests, musical diversion, song writing, and therapeutic singing (Mandel 2019). • The use of alternative and complementary therapies, such as acupuncture, guided imagery, cognitive-behavioral therapy, and hypnosis have not been systemically evaluated for use in the Acute care setting including ED. (Dillan 2005, Hoffman 2007) • In general, their application may be limited for a single visit, but continued investigation in their safety and efficacy is strongly encouraged. • Practitioners may also consider utilization of osteopathic manipulation techniques, such as high velocity, low amplitude techniques, muscle energy techniques, and soft tissue techniques for patients presenting to the acute care setting with pain syndromes of skeletal, arthroidal, or myofascial origins. (Eisenhart 2003) Opioids • Acute Care providers are uniquely positioned to combat the opioid epidemic by thoughtful prescribing of parenteral and oral opioids in inpatient setting and upon discharge, and through their engagement with opioid addicted patients in acute care setting. • Acute Care providers should make every effort to utilize non-pharmacological modalities and non-opioid analgesics to alleviate pain, and to use opioid analgesics only when the benefits of opioids are felt to outweigh the risks. (not routinely) • When opioids are used for acute pain, clinicians should combine them with non-pharmacologic and non-opioid pharmacologic therapy: Yoga, exercise, cognitive behavioral therapy, complementary/alternative medical therapies (acupuncture); NSAID's, Acetaminophen, Topical Analgesics, Nerve blocks, etc. • When considering opioids for acute pain, Acute Care providers should involve patients in shared decision-making about analgesic options and opioid alternatives, risks and benefits of opioid therapies, and rational expectations about the pain trajectory and management approach. • When considering opioids for acute pain, acute care providers should counsel patients regarding serious adverse effects such as sedation and respiratory depression, pruritus and constipation, and rapid development of tolerance and hyperalgesia. • When considering administration of opioids for acute pain, acute care providers should make every effort to accesses respective state's Prescription Drug Monitoring Program (PDMP). The data obtained from PDMP's to be used to identify excessive dosages and dangerous combinations, identify and counsel patients with opioid use disorder, offer referral for addiction treatment. • PDMPs can provide clinicians with comprehensive prescribing information to improve clinical decisions around opioids. However, PDMPs vary tremendously in their accessibility and usability in the ED, which limits their effectiveness at the point of care. Problems are complicated by varying state-to-state requirements for data availability and accessibility. Several potential solutions to improving the utility of PDMPs in EDs include integrating PDMPs with electronic health records, implementing unsolicited reporting and prescription context, improving PDMP accessibility, data analytics, and expanding the scope of PDMPs. (Eldert et al, 2018) • Parenteral opioids when used in titratable fashion are effective, safe, and easily reversible analgesics that quickly relieve pain. • Acute care clinicians should consider administering these analgesics for patients in acute pain where the likelihood of analgesic benefit is judged to exceed the likelihood of harm. • Parenteral opioids must be titrated regardless of their initial dosing regimens (weight-based or fixed) until pain is optimized to acceptable level (functionality status) or side effects become intolerable. • When parenteral opioids are used, patients should be engaged in shared-decision making regarding the route of administration, as repetitive attempts of IV cannulation and intramuscular injections are associated with pain. In addition, intramuscular injections are associated with unpredictable absorption rates, and complications such as muscle necrosis, soft tissue infection and the need for dose escalation. (Von Kemp 1989, Yamanaka 1985, Johnson 1976) • Morphine sulfate provides better balance of analgesic efficacy and safety among all parenteral opioids. a. Dosing regimens and routes: b. IV: 0.05-0.1mg/kg to start, titrate q 10-20 min c. IV: 4-6 mg fixed, titrate q 10-20 min d. SQ: 4-6 mg fixed, titrate q 20 min e. Nebulized: 0.2 mg/kg or 10-20 mg fixed, repeat q 15-20 min f. PCA: prone to dosing errors g. IM: should be avoided (pain, muscle fibrosis, necrosis, increase in dosing requirements) • Hydromorphone should be avoided as a first-line opioid due to significant euphoria and severe respiratory depression requiring naloxone reversal. Due to higher lipophilicity, Hydromorphone use is associated with higher rates of euphoria and subsequent development of addiction. Should hydromorphone be administered in higher than equi-analgesic morphine milligram equivalents, close cardiopulmonary monitoring is strongly recommended. Dosing h. IV: 0.2-0.5 mg initial, titrate q10-15 min i. IM: to be avoided (pain, muscle fibrosis, necrosis, increase in dosing requirements) j. PCA: prone to dosing errors (severe CNS and respiratory depression) k. Significantly worse AE profile in comparison to Morphine l. Equianalgesic IV conversion (1 mg HM=8mg of MS) m. Overprescribed in >50% of patients n. Inappropriately large dosing in EM literature: 2 mg IVP o. Abuse potential (severely euphoric due to lipophilicity) • Fentanyl is the most potent opioid, short-acting, requires frequent titration. Dosing: p. IV: 0.25-0.5 μg/kg (WB), titrate q10 min q. IV: 25-50 μg (fixed), titrate q10 min r. Nebulization: 2-4 μg/kg, titrate q20-30 min s. IN: 1-2 μg/kg, titrate q5-10min t. Transbuccal: 100-200μg disolvable tablets u. Transmucosal: 15-20 mcg/kg Lollypops • Opioids in Renal Insufficiency/Renal Failure Patients-requires balance of ORAE with pain control by starting with lower-than-recommended doses and slowly titrate up the dose while extending the dosing interval. (Dean 2004, Wright 2011) • Opioid-induced pruritus is centrally mediated process via μ-opioid receptors as naloxone, nalbuphine reverse it, and can be caused by opioids w/o histamine release (Fentanyl). Use ultra-low-dose naloxone of 0.25 -1 mcg/kg/hr with NNT of 3.5. (Kjellberg 2001) • When intravascular access is unobtainable, acute care clinicians should consider utilization of intranasal (fentanyl), nebulized (fentanyl and morphine), or transmucosal (rapidly dissolvable fentanyl tablets) routes of analgesic administration for patients with acute painful conditions. • Breath actuated nebulizer (BAN): enclosed canister, dual mode: continuous and on-demand, less occupational exposures. a. Fentanyl: 2-4 mcg//kg for children, 4 mcg/kg for adults: titration q 10 min up to three doses via breath-actuated nebulizer (BAN): systemic bioavailability of 50-60% of IV route. (Miner 2007, Furyk 2009, Farahmand 2014) b. Morphine: 10-20 mg g10 min up to 3 doses via breath-actuated nebulizer (BAN)-Systemic bioavailability (concentration) of 30-35% of IV Route. (Fulda 2005, Bounes 2009, Grissa 2015) c. Intranasal Fentanyl: IN via MAD at 1-2 mcg/kg titration q 5 min (use highly concentrated solution of 100mcg/ml for adults and 50 mcg/ml for children)- systemic bioavailability of 90% of IV dosing. (Karisen 2013, Borland 2007, Saunders 2010, Holdgate 2010) d. IN route: shorter time to analgesia, titratable, comparable pain relief to IV route, minimal amount of side effects, similar rates of rescue analgesia, great patients and staff satisfaction. Disadvantages: requires highly concentrated solutions that not readily available in the ED, contraindicated in facial/nasal trauma. Oral Opioids • Oral opioid administration is effective for most patients in the acute care setting, however, there is no appreciable analgesic difference between commonly used opioids (oxycodone, hydrocodone and morphine sulfate immediate release (MSIR). • When oral opioids are used for acute pain, the lowest effective dose and fewest number of tablets needed should be prescribed. In most cases, less than 3 days' worth are necessary, and rarely more than 5 days' worth are needed. • If painful condition outlasts three-day supply, re-evaluation in health-care facility is beneficial. Consider expediting follow-up care if the patient's condition is expected to require more than a three-day supply of opioid analgesics. • Only Immediate release (short-acting) formulary are to be prescribed in the acute care setting and at discharge. • Clinicians should not administer or prescribe long-acting, extended-release, or sustained-release opioid formulations, which include both oral and transdermal (fentanyl) medications in the acute care setting. These formulations are not indicated for acute pain and carry a high risk of overdose, particularly in opioid-naïve patients. • Acute care providers should counsel patients about safe medication storage and disposal, as well as the consequences of failure to do this; potential for abuse and misuse by others (teens and young adults), and potential for overdose and death (children and teens). • Oxycodone is no more effective than other opioids (hydrocodone, MSIR). Oxycodone has highest potential for abuse, misuse and diversion as well as increased risks of overdose, addiction and death. Oxycodone should be avoided as a first-line oral opioid for acute pain. ( Strayer 2016) • If still prescribed, lowest dose (5mg) in combination with acetaminophen (lowest dose of 325 mg) should be considered as it associated with less abuse and diversion (in theory). Potential for acetaminophen overdose exist though with combination. • Hydrocodone is three times more prescribed than oxycodone, but three times less used for non-medical purpose. Combo with APAP (Vicodin)-Use lowest effective dose for hydrocodone and APAP (5/325). (Quinn 1997, Adams 2006) • Immediate release morphine sulfate (MSIR) administration is associated with lesser degree of euphoria and consequently, less abuse potential (Wightman 2012). ED providers should consider prescribing Morphine Sulfate Immediate Release Tablets (MSIR) (Wong 2012, Campos 2014) for acute pain due to: o Similar analgesic efficacy to Oxycodone and Hydrocodone o Less euphoria (less abuse potential) o Less street value (less diversion) o More dysphoria in large doses o Less abuse liability and likeability • Tramadol should not be used in acute care setting and at discharge due to severe risks of adverse effects, drug-drug interactions, and overdose. There is very limited data supporting better analgesic efficacy of tramadol in comparison to placebo, or better analgesia than APAP or Ibuprofen. Tramadol dose not match analgesic efficacy of traditional opioids. (Juurlink 2018, Jasinski 1993, Babalonis 2013) • Side effects are: o Seizures o Hypoglycemia o Hyponatremia o Serotonin syndrome o Abuse and addiction • Codeine and Codeine/APAP is a weak analgesic that provides no better pain relief than placebo. Codeine must not be administered to children due to: o dangers of the polymorphisms of the cytochrome P450 iso-enzyme: o ultra-rapid metabolizers: respiratory depression and death o poor metabolizers: absent or insufficient pain relief • Transmucosal fentanyl (15 and 20 mcg/kg lollypops) has an onset of analgesia in 5 to 15 minutes with a peak effect seen in 15 to 30 minutes (Arthur 2012). • Transbuccal route can be used right at the triage to provide rapid analgesia and as a bridge to intravenous analgesia in acute care setting. (Ashburn 2011). A rapidly dissolving trans-buccal fentanyl (100mcg dose) provides fast pain relief onset (median 10 min), great analgesics efficacy, minimal need for rescue medication and lack of side effects in comparison to oxycodone/acetaminophen tablet (Shear 2010) • Morphine Milligram Equivalent (MME) is a numerical standard against which most opioids can be compared, yielding a comparison of each medication's potency. MME does not give any information of medications efficacy or how well medication works, but it is used to assess comparative potency of other analgesics. • By converting the dose of an opioid to a morphine equivalent dose, a clinician can determine whether a cumulative daily dose of opioids approaches an amount associated with increased risk of overdose and to identify patients who may benefit from closer monitoring, reduction or tapering of opioids, prescribing of naloxone, and other measures to reduce risk of overdose. • Opioid-induced hyperalgesia: o opioid-induced hyperalgesia (OIH) is a rare syndrome of increasing pain, often accompanied by neuroexcitatory effects, in the setting of increasing opioid therapy. o Morphine is by far the most common opiate implicated in OIH. Hydromorphone and oxycodone, members of the same class of opiate as morphine (phenanthrenes), can also cause OIH. Fentanyl, a synthetic opioid in the class of phenylpiperidine, is less likely to precipitate OIH. Existing data suggests that OIH is caused by multiple opioid-induced changes to the central nervous system including: -Activation of N-methyl-D-aspartate (NMDA) receptors -Inhibition of the glutamate transporter system -Increased levels of the pro-nociceptive peptides within the dorsal root ganglia -Activation of descending pain facilitation from the rostral ventromedial medulla -Neuroexcitatory effects provoked by metabolites of morphine and hydromorphone • OIH can be confused with tolerance as in both cases patients report increased pain on opioids. The two conditions can be differentiated based on the patient's response to opioids. In tolerance, the patient's pain will improve with dose escalation. In OIH, pain will worsen with opioid administration. This paradoxical effect is one of the hallmarks of the syndrome. Non-opioid analgesics • Acetaminophen is indicated for management of mild to moderate pain and as a single analgesic and has modest efficacy at most. Addition of Acetaminophen to Ibuprofen does not provide better analgesia for patients with acute low back pain. The greatest limitation to the use of intravenous (IV) versus oral acetaminophen is the nearly 100-fold cost differential, which is likely not justified by any marginal improvement in pain relief. Furthermore, IV APAP provide faster onset of analgesia only after an initial dose. (Yeh 2012, Serinken 2012) • NSAIDs should be administered at their lowest effective analgesic doses both in the ED and upon discharge and should be given for the shortest appropriate treatment course. Caution is strongly advised when NSAIDs are used in patients at risk for renal insufficiency, heart failure, and gastrointestinal hemorrhage, as well as in the elderly. Strong consideration should be given to topical NSAID's in managing as variety of acute and chronic painful Musculo-skeletal syndromes. The analgesic ceiling refers to the dose of a drug beyond which any further dose increase will not result in additional analgesic efficacy. Thus, the analgesics ceiling for ibuprofen is 400 mg per dose (1200 mg/24 h) and for ketorolac is 10 mg per dose (10 mg/24 h). These doses are less than those often prescribed for control of inflammation and fever. When it comes to equipotent doses of different NSAIDs, there is no difference in analgesic efficacy. • Ketamine, at sub-dissociative doses (also known as low-dose ketamine or analgesic dose ketamine) of 0.1 to 0.4 mg/kg, provided effective analgesia as a single agent or as an adjunct to opioids (reducing the need for opioids) in the treatment of acute traumatic and nontraumatic pain in the ED. This effective analgesia, however, must be balanced against high rates of minor adverse side effects (14%–80%), though typically short-lived and not requiring intervention. In addition to IV rout, ketamine can be administered via IN,SQ, and Nebulized route. • Local anesthetics are widely used in the ED for topical, local, regional, intra-articular, and systemic anesthesia and analgesia. Local anesthetics (esters and amides) possess analgesic and anti-hyperalgesic properties by non-competitively blocking neuronal sodium channels. o Topical analgesics containing lidocaine come in patches, ointments, and creams have been used to treat pain from acute sprains, strains, and contusions as well as variety of acute inflammatory and chronic neuropathic conditions, including postherpetic neuralgia (PHN), complex regional pain syndromes (CRPS) and painful diabetic neuropathy (PDN). o UGRA used for patients with lower extremity fractures or dislocations (eg, femoral nerve block, fascia iliaca compartment block) demonstrated significant pain control, decreased need for rescue analgesia, and first-attempt procedural success. In addition, UGRA demonstrated few procedural complications, minimal need for rescue analgesia, and great patient satisfaction. o Analgesic efficacy and safety of IV lidocaine has been evaluated in patients with renal colic and acute lower back pain. Although promising, this therapy will need to be studied in larger populations with underlying cardiac disease before it can be broadly used. o knvlsd • Antidopaminergic and Neuroleptics are frequently used in acute care settings for treatment of migraine headache, chronic abdominal pain, cannabis-induced hyperemesis. • Anti-convulsant (gabapentin and pregabalin) are not recommended for management of acute pain unless pain is of neuropathic origin. Side effects, particularly when combined with opioids (potentiation of euphoria and respiratory depression), titration to effect, and poor patients' compliance are limiting factors to their use. (Peckham 2018) References: Chang HY, Daubresse M, Kruszewski SP, et al. Prevalence and treatment of pain in EDs in the United States, 2000 to 2010. Am J Emerg Med 2014;32(5):421–31. Green SM. There is oligo-evidence for oligoanalgesia. Ann Emerg Med 2012;60: 212–4. Strayer RJ, Motov SM, Nelson LS. Something for pain: Responsible opioid use in emergency medicine. Am J Emerg Med. 2017 Feb;35(2):337-341. Smith RJ, Rhodes K, Paciotti B, Kelly S,et al. Patient Perspectives of Acute Pain Management in the Era of the Opioid Epidemic. Ann Emerg Med. 2015 Sep;66(3):246-252 Meisel ZF, Smith RJ. Engaging patients around the risks of opioid misuse in the emergency department. Pain Manag. 2015 Sep;5(5):323-6. Wightman R, Perrone J. (2017). Opioids. In Strayer R, Motov S, Nelson L (Eds.), Management of Pain and Procedural Sedation in Acute Care. http://painandpsa.org/opioids/ Motov S, Nelson L, Advanced Concepts and Controversies in Emergency Department Pain Management. Anesthesiol Clin. 2016 Jun;34(2):271-85. doi: 10.1016/j.anclin.2016.01.006. Ducharme J. Non-opioid pain medications to consider for emergency department patients. Available at: http://www.acepnow.com/article/non-opioid-painmedications- consider-emergency-department-patients/. 2015. Wightman R, Perrone J, Portelli I, et al. Likeability and Abuse Liability of Commonly Prescribed Opioids. J Med Toxicol. September 2012. doi: 10.1007/s12181-012-0263-x Zacny JP, Lichtor SA. Within-subject comparison of the psychopharmacological profiles of oral oxycodone and oral morphine in non-drug-abusing volunteers. Psychopharmacology (Berl) 2008 Jan;196(1):105–16. Hoppe JA, Nelson LS, Perrone J, Weiner SG, Prescribing Opioids Safely in the Emergency Department (POSED) Study Investigators. Opioid Prescribing in a Cross Section of US Emergency Departments. Ann Emerg Med. 2015;66(3):253–259. Baehren DF, Marco CA, Droz DE, et al. A statewide prescription monitoring program affects emergency department prescribing behaviors. Ann Emerg Med. 2010; 56(1):19–23 Weiner SG, Griggs CA, Mitchell PM, et al. Clinician impression versus prescription drug monitoring program criteria in the assessment of drug-seeking behavior in the emergency department. Ann Emerg Med 2013;62(4):281–9. Greenwood-Ericksen MB, Poon SJ, Nelson LS, Weiner SG, et al. Best Practices for Prescription Drug Monitoring Programs in the Emergency Department Setting: Results of an Expert Panel. Ann Emerg Med. 2016 Jun;67(6):755-764 Patanwala AE, Keim SM, Erstad BL. Intravenous opioids for severe acute pain in the emergency department. Ann Pharmacother 2010;44(11):1800–9. Bijur PE, Kenny MK, Gallagher EJ. Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in the majority of patients. Ann Emerg Med 2005; 46:362–7. Birnbaum A, Esses D, Bijur PE, et al. Randomized double-blind placebo- controlled trial of two intravenous morphine dosages (0.10 mg/kg and 0.15 mg/kg) in emergency department patients with moderate to severe acute pain. Ann Emerg Med. 2007;49(4):445–53. Patanwala AE, Edwards CJ, Stolz L, et al. Should morphine dosing be weight based for analgesia in the emergency department? J Opioid Manag 2012; 8(1):51–5. Lvovschi V, Auburn F, Bonnet P, et al. Intravenous morphine titration to treat severe pain in the ED. Am J Emerg Med 2008;26:676–82. Chang AK, Bijur PE, Napolitano A, Lupow J, et al. Two milligrams i.v. hydromorphone is efficacious for treating pain but is associated with oxygen desaturation. J Opioid Manag. 2009 Mar-Apr;5(2):75-80. Sutter ME, Wintemute GJ, Clarke SO, et al. The changing use of intravenous opioids in an emergency department. West J Emerg Med 2015;16:1079-83. Miner JR, Kletti C, Herold M, et al. Randomized clinical trial of nebulized fentanyl citrate versus i.v. fentanyl citrate in children presenting to the emergency department with acute pain. Acad Emerg Med 2007;14:895–8. Furyk JS, Grabowski WJ, Black LH. Nebulized fentanyl versus intravenous morphine in children with suspected limb fractures in the emergency department: a randomized controlled trial. Emerg Med Australas 2009;21:203–9. Borland M, Jacobs I, King B, et al. A randomized controlled trial comparing intranasal fentanyl to intravenous morphine for managing acute pain in children in the emergency department. Ann Emerg Med 2007;49:335–40 Im DD, Jambaulikar GD, Kikut A, Gale J, Weiner SG. Brief Pain Inventory-Short Form: A New Method for Assessing Pain in the Emergency Department. Pain Med. 2020 Sep 11:ppnaa269. doi: 10.1093/pm/pnaa269. Epub ahead of print. PMID: 32918473. Mandel SE, Davis BA, Secic M. Patient Satisfaction and Benefits of Music Therapy Services to Manage Stress and Pain in the Hospital Emergency Department. J Music Ther. 2019 May 10;56(2):149-173. Piatka C, Beckett RD. Propofol for Treatment of Acute Migraine in the Emergency Department: A Systematic Review. Acad Emerg Med. 2020 Feb;27(2):148-160. Tzabazis A, Kori S, Mechanic J, Miller J, Pascual C, Manering N, Carson D, Klukinov M, Spierings E, Jacobs D, Cuellar J, Frey WH 2nd, Hanson L, Angst M, Yeomans DC. Oxytocin and Migraine Headache. Headache. 2017 May;57 Suppl 2:64-75. doi: 10.1111/head.13082. PMID: 28485846. Yeh YC, Reddy P. Clinical and economic evidence for intravenous acetaminophen. Pharmacotherapy 2012;32(6):559–79. Serinken M, Eken C, Turkcuer I, et al. Intravenous paracetamol versus morphine for renal colic in the emergency department: a randomised double-blinded controlled trial. Emerg Med J 2012;29(11):902–5. Wright JM, Price SD, Watson WA. NSAID use and efficacy in the emergency department: single doses of oral ibuprofen versus intramuscular ketorolac. Ann Pharmacother 1994;28(3):309–12. Turturro MA, Paris PM, Seaberg DC. Intramuscular ketorolac versus oral ibuprofen in acute musculoskeletal pain. Ann Emerg Med 1995;26(2):117–20. Catapano MS. The analgesic efficacy of ketorolac for acute pain [review]. J Emerg Med 1996;14(1):67–75 Dillard JN, Knapp S. Complementary and alternative pain therapy in the emergency department. Emerg Med Clin North Am 2005; 23:529–549. Hoffman BM, Papas RK, Chatkoff DK, Kerns RD. Meta-analysis of psychological interventions for chronic low back pain. Health Psychol 2007;26:1–9. Eisenhart AW, Gaeta TJ, Yens DP. Osteopathic manipulative treatment in the emergency department for patients with acute ankle injuries. J Am Osteopath Assoc 2003;103:417–421.
Contributor: Aaron Lessen, MD Educational Pearls: Contrary to many assumptions, meter-dose inhalers (MDIs) are as effective as nebulizers in pediatric and adult patients Nebulizers are associated with higher rates of tremor, tachycardia; they cost more and are associated with longer ED stays Though it may take some convincing, in a patient that is physically able, using an MDI with spacer appears to be the better option - and that was even before COVID. References Snider MA, Wan JY, Jacobs J, Kink R, Gilmore B, Arnold SR. A Randomized Trial Comparing Metered Dose Inhalers and Breath Actuated Nebulizers. J Emerg Med. 2018 Jul;55(1):7-14. doi: 10.1016/j.jemermed.2018.03.002. Epub 2018 Apr 30. PMID: 29716819. Brocklebank D, Ram F, Wright J, Barry P, Cates C, Davies L, Douglas G, Muers M, Smith D, White J. Comparison of the effectiveness of inhaler devices in asthma and chronic obstructive airways disease: a systematic review of the literature. Health Technol Assess. 2001;5(26):1-149. doi: 10.3310/hta5260. PMID: 11701099. Dhuper S, Chandra A, Ahmed A, Bista S, Moghekar A, Verma R, Chong C, Shim C, Cohen H, Choksi S. Efficacy and cost comparisons of bronchodilatator administration between metered dose inhalers with disposable spacers and nebulizers for acute asthma treatment. J Emerg Med. 2011 Mar;40(3):247-55. doi: 10.1016/j.jemermed.2008.06.029. Epub 2008 Dec 11. PMID: 19081697. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD The Emergency Medical Minute is excited to announce that we are now offering AMA PRA Category 1 credits™ via online course modules. To access these and for more information, visit our website at www.emergencymedicalminute.com/cme-courses/ and create an account.
Contributor: Sam Killian, MD Educational Pearls: Droperidol (Inapsine) is an antipsychotic drug with efficacy for nausea, vomiting, headaches, and treating agitation In the early 2000’s, Droperidol received a black box warning for QT prolongation This caused a precipitous drop of in administration and ultimately led to a stop in production More careful analysis since has called into question the true incidence of QT prolongation in typical dosing Retrospective review published this year looked at 15,374 non-critical and 1,172 critical patients who received droperidol with only a single episode of Torsades des pointes (which was attributed to multiple other risk factors) Of the 2,431 non-critical patients, and 396 critical patients, who received an ECG before and after administration, there were no changes to the mean QTc Droperidol is being manufactured again and the prior black box warning being called into question, so it will likely begin to become more widely available for use References Cole JB, Lee SC, Martel ML, Smith SW, Biros MH, Miner JR. The Incidence of QT Prolongation and Torsades des Pointes in Patients Receiving Droperidol in an Urban Emergency Department. West J Emerg Med. 2020 Jul 2;21(4):728-736. doi: 10.5811/westjem.2020.4.47036. PMID: 32726229; PMCID: PMC7390553. Perkins J, Ho JD, Vilke GM, DeMers G. American Academy of Emergency Medicine Position Statement: Safety of Droperidol Use in the Emergency Department. J Emerg Med. 2015 Jul;49(1):91-7. doi: 10.1016/j.jemermed.2014.12.024. Epub 2015 Mar 30. PMID: 25837231. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD
Contributor: Aaron Lessen, MD Educational Pearls: Carbonated beverages have shown efficacy in helping patients spontaneously pass esophageal food impactions Glucagon, while historically used for treatment, has been shown to have significant side effects without any clinical benefit Definitive treatment is with endoscopy performed typically by a gastroenterologist References Long B, Koyfman A, Gottlieb M. Esophageal Foreign Bodies and Obstruction in the Emergency Department Setting: An Evidence-Based Review. J Emerg Med. 2019;56(5):499-511. doi:10.1016/j.jemermed.2019.01.025 Peksa GD, DeMott JM, Slocum GW, Burkins J, Gottlieb M. Glucagon for Relief of Acute Esophageal Foreign Bodies and Food Impactions: A Systematic Review and Meta-Analysis. Pharmacotherapy. 2019;39(4):463-472. doi:10.1002/phar.2236 Akram J, Amin FM, Toft JG, Rømeling F. Håndtering af fremmedlegeme i øsofagus med synkestop [Treatment of foreign body impactions in oesophagus]. Ugeskr Laeger. 2013;175(10):640-643. Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD
Contributor: Don Stader, MD Educational Pearls: Toxic shock syndrome (TSS) is a rare cause of shock typically caused by Staph aureus or Strep pyogenes, that produces a toxin that leads to rapid onset hypotension with a diffuse erythematous rash. Signs of TSS may include rapid onset of altered mental status, dizziness, nausea, abdominal discomfort, hypotension, and rash TSS is associated with foreign bodies, such as tampons or nasal packing - make sure to remove any offending object Clindamycin is the drug of choice because it stops protein synthesis which helps treat toxic shock because toxic shock is caused by a protein (TSST-1) made by the bacteria. TSS is associated iwth high morbidity and mortality despite treatments Despite the association with TSS, there is little supporting evidence for prophylactic antibiotics when placing nasal packing References Gottlieb M, Long B, Koyfman A. The Evaluation and Management of Toxic Shock Syndrome in the Emergency Department: A Review of the Literature. J Emerg Med. 2018;54(6):807-814. doi:10.1016/j.jemermed.2017.12.048 Lange JL, Peeden EH, Stringer SP. Are prophylactic systemic antibiotics necessary with nasal packing? A systematic review. Am J Rhinol Allergy. 2017;31(4):240-247. doi:10.2500/ajra.2017.31.4454 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD
Contributor: Don Stader, MD Educational Pearls: Checkpoint inhibition normally helps our body detect abnormal cells and terminate it but cancerous cells often are able to avoid this countermeasure Monoclonal antibodies that bind to checkpoint inhibitors can stop cancerous cells from turning off immunologic T cells and allows the immune system to continue to attack cancers. These therapies carry risks of exacerbating autoimmune problems due to the ramped up immune response Most often this autoimmune attack leads to skin and GI symptoms but can affect many other organ systems. In the emergency room this can present many different ways, but the mainstay of treatment is steroids to stop these exacerbations. Chimeric Antigen Receptor (CAR) T-cell Therapy is another immunotherapy where antigens to a cancerous cell are re-introduced to spur a directed immune response Cytokine release syndrome can occur in these patients and mimic other presentations such as septic shock, a result of tumor break down This is treated with steroids and monoclonal antibodies that help thwart the cytokine release References Hay, KA. Cytokine release syndrome and neurotoxicity after CD19 chimeric antigen receptor-modified (CAR-) T cell therapy. Br J Haematol. 2018 Nov;183(3):364-374. doi: 10.1111/bjh.15644. Epub 2018 Nov 8. Hryniewicki AT, Wang C, Shatsky RA, Coyne CJ. Management of Immune Checkpoint Inhibitor Toxicities: A Review and Clinical Guideline for Emergency Physicians. J Emerg Med. 2018;55(4):489-502. doi:10.1016/j.jemermed.2018.07.005 Summarized by Jackson Roos, MS4 | Edited by Erik Verzemnieks, MD
Contributor: Sam Killian, MD Educational Pearls: Classic dogma teaching that epinephrine should not be used in the fingers, nose, penis, and toes when performing local anesthesia due to concerns for ischemia is wrong This has been well documented in multiple literature reviews A prospective, randomized double-blind study compared lidocaine vs lidocaine with epinephrine for finger injuries and the use of epinephrine was associated with less bleeding and better anesthesia Editor’s note: in the lidocaine without epinephrine group, 5 (not 7) needed additional dosing of local anesthesia. The groups were also split 29 for lidocaine alone and 31 for lidocaine with epinephrine but we’re in a pandemic so who is noticing anyways References 1. Wilhelmi, B.J., et al. Do not use epinephrine in digital blocks: myth or truth? Plast Reconstr Surg. 2001 Feb;107(2):393-7. 2. Ilicki, J. Safety of Epinephrine in Digital Nerve Blocks: A Literature Review. J Emerg Med. 2015 Nov;49(5):799-809. doi: 10.1016/j.jemermed.2015.05.038. Epub 2015 Aug 4. 3. Walsh, K., Baker, B.G., Iyer, S. Adrenaline Auto-injector injuries to digits; a systematic review and recommendations for emergency management. 2020 Feb 8. pii: S1479-666X(20)30016-0. doi: 10.1016/j.surge.2020.01.005. Summarized by Jackson Roos, MS3 | Edited by Erik Verzemnieks, MD
The Podcasts of the Royal New Zealand College of Urgent Care
Can you consider prescribing an antibiotic when the patient reports a previous reaction? Dr Josh Russell is trained in Emergency Medicine in the USA but works now in Urgent Care. He is the editor in chief of the Journal of Urgent Care Medicine and a contributor to the Hippo Education UC:RAP Check out the Hippo Education site - www.hippoed.com The January 2020 Urgent Care RAP features a more in-depth discussion on low risk antibiotic reactions. The following papers are those used by Josh to come to his conclusions. Campagna J et al. The use of cephalosporins in penicillin allergic patients: a literature review. J Emerg Med 2012;42(5):612-20 https://www.ncbi.nlm.nih.gov/pubmed/?term=Campagna+J%2C+et+al.+The+use+of+cephalosporins+in+penicillin-allergic+patients%3A+a+literature Shenoy ES et al. Evaluation and Management of Penicillin Allergy: A review. JAMA 2019;321(2):188-99 https://www.ncbi.nlm.nih.gov/pubmed/?term=Shenoy+ES%2C+et+al.+Evaluation+and+Management+of+Penicillin+Allergy%3A+A+review.+JAMA+2019%3B321(2)%3A188-99 Pichichero ME et al. Penicillin and cephalosporin allergy. Ann Allergy Asthma Immunol 2014; 112:404-12 Check out the Journal of Urgent Care Medicine - https://www.jucm.com Follow Josh on Twitter - @UCPracticeTips https://twitter.com/UCPracticeTips www.rnzcuc.org.nz podcast@rnzcuc.org.nz https://www.facebook.com/rnzcuc https://twitter.com/rnzcuc Music licensed from www.premiumbeat.com Full Grip by ScoreSquad This podcast is intended to assist in ongoing medical education and peer discussion for qualified health professionals. Please ensure you work within your scope of practice at all times. For personal medical advice always consult your usual doctor
Pallicast - Podcast da Academia Nacional de Cuidados Paliativos
Apresentação: Cláudia Inhaia – cinhaia@gmail.comInstagram @cinhaiaTwitter @cinhaiaConvidada:Sabrina Corrêa da Costa Ribeiro – sabrina.ribeiro@hc.fm.usp.br Instagram @papopaliativo Twitter @Uti.CorreaQuem tiver interesse em enviar seus comentários, sugestões de temas e participantes para o PodCast basta enviar um e-mail para pallicast.ancp@paliativo.org.brSiga também a ANCP em suas redes sociais:https://www.facebook.com/ANCPaliativoshttps://twitter.com/ancpaliativoshttps://www.youtube.com/user/TVANCP/https://www.linkedin.com/company/ancp/CHAMADA De acordo com a Organização Mundial de Saúde, em torno de 40 milhões de pessoas necessitam de cuidado paliativo, estando 78% delas em países de média ou baixa renda. Apenas 14% destas pessoas conseguem ter acesso a cuidado paliativo. Paciente com doenças crônicas e incuráveis, idosos frágeis, pacientes com doenças degenerativas ou sintomas mal controlados muitas vezes têm na emergência seu único acesso imediato a atenção em saúde. Habilidades em cuidado paliativo são essenciais não só para identificar pacientes com esta necessidade como para aliviar corretamente os sintomas, comunicar más notícia de forma adequada e elaborar um plano de cuidado que respeite os valores do paciente, mesmo em uma situação em que o paciente é desconhecido, não pode falar por si e decisões precisam ser tomadas rapidamente.Nesse episódio Sabrina Corrêa da Costa Ribeiro, coordenadora do comitê de Cuidados Paliativos em Emergências da ANCP fala sobre os desafios do atendimento na emergência.Informamos que a opinião do entrevistado não necessariamente reflete a opinião da ANCP.INDICAÇÕES DOS ENTREVISTADOS: 1- Ensaio sobre a cegueira. José Saramago 19952- Elza o Musical - Direção Duda Maia 2019-20203- Bacurau - Direção Kleber Mendonça, 20194- Palliative aspects of emergency care. Paul Desandre e Tammie Quest, Oxford University Press 20135- Forte D, Kawai F, Cohen C. A bioethical framework to guide decision-making process in the care of seriously ill patients. BMC Medical Ethics 2018;18:786- Palliative care for adults in the emergency department. Tammie Quest, Sangeeta Lamb uptodate.com (acessado em 29/1/2020)7- Duncan R., Thakore S. Decreased Glasgow Coma Score does not mandate endotracheal intubation in the emergency department. J Emerg Med 2009; 37(4):451-4558- Ouchi K, Jambaulikar G, Hohman S et al. Prognosis after emergency department intubation to inform shared decision-making. J Am Geriatr Soc 2018; 66 (7): 1377-1381 EDIÇÃO: Press Start - Arte e Entretenimento (@abc_ishie)DIRECIONAMENTO METADADOS#emergência #emergency #cuidadopaliativo #palliativecare #epec #CPnaemergencia #ancp #symptommanagement #controledesintomas #necpal #autonomia #ortotanasia #GOC #goalsofcare #bioetica #bioethics #decisaocompartilhada #intubação #rebaixamento #idosos #elderly #comitêsancp
Contributor: Don Stader, MD Educational Pearls: High-quality compressions are an essential, and probably one of the most important, part of cardiac arrest Actual evidence for drugs in cardiac arrest included in ACLS are limited, including epinephrine, bicarbonate, amiodarone, etc. Early defibrillation for ventricular tachycardia (VT) or ventricular fibrillation (VF) has a plethora of supporting evidence Double-sequential defibrillation (nearly simultaneous defibrillation using 2 machines) may be considered for refractory dysrhythmias like VF tPA during a cardiac arrest can be considered in the setting of massive PE (although the evidence supporting this practice is poor) Ending a cardiac arrest resuscitation is a difficult decision and use of ultrasound may be helpful to assess for meaningful cardiac function/activity References Link MS, Berkow LC, Kudenchuk PJ, Halperin HR, Hess EP, Moitra VK, Neumar RW, O'Neil BJ, Paxton JH, Silvers SM, White RD, Yannopoulos D, Donnino MW . Part 7: Adult Advanced Cardiovascular Life Support: 2015 American Heart Association Guidelines Update for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2015 Nov;132(18 Suppl 2):S444-64. Wang Y, Wang M, Ni Y, Liang B, Liang Z. Can Systemic Thrombolysis Improve Prognosis of Cardiac Arrest Patients During Cardiopulmonary Resuscitation? A Systematic Review and Meta-Analysis.J Emerg Med. 2019;57(4):478. Epub 2019 Oct 5. Eric Cortez, William Krebs, James Davis, David P. Keseg, Ashish R. Panchal. Use of double sequential external defibrillation for refractory ventricular fibrillation during out-of-hospital cardiac arrest. Resuscitation. Volume 108. 2016. Pages 82-86, Atkinson PR, Beckett N, French J, Banerjee A, Fraser J, Lewis D. Does Point-of-care Ultrasound Use Impact Resuscitation Length, Rates of Intervention, and Clinical Outcomes During Cardiac Arrest? A Study from the Sonography in Hypotension and Cardiac Arrest in the Emergency Department (SHoC-ED) Investigators. Cureus. 2019;11(4):e4456. Published 2019 Apr 13. doi:10.7759/cureus.4456 Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD
Contributor: Michael Hunt, MD Educational Pearls: Cirrhosis is the end stage of chronic structural damage to the liver. This is most commonly due to alcohol but other causes viral hepatitis and hepatotoxic drugs Cirrhotic patients are very prone to GI bleeding and infections, partially due to the role the liver plays in producing immune and clotting factors These patients can easily become “sick”. Use the shock index (heart rate / systolic blood pressure) as a rapid assessment of hemodynamic status. >0.7 is worrisome, >1 should prompt resuscitation. Because cirrhotic patients are immunocompromised, do not rely on the presence of fever and peritonitis to diagnose spontaneous bacterial peritonitis (SBP), and have a low threshold to perform a diagnostic paracentesis Polymorphonuclear (PMN) count > 250 in the ascitic fluid suggests SBP With GI bleeding in cirrhotics, antibiotics have a mortality benefit, while PPIs and octreotide have limited benefit References Chinnock B, Hendey GW, Minnigan H, Butler J, Afarian H. Clinical impression and ascites appearance do not rule out bacterial peritonitis. J Emerg Med. 2013 May;44(5):903-9. doi: 10.1016/j.jemermed.2012.07.086. Epub 2013 Mar 7. Pericleous M, Sarnowski A, Moore A, Fijten R, Zaman M. The clinical management of abdominal ascites, spontaneous bacterial peritonitis and hepatorenal syndrome: a review of current guidelines and recommendations. Eur J Gastroenterol Hepatol. 2016 Mar;28(3):e10-8. doi: 10.1097/MEG.0000000000000548. Chavez-Tapia NC, Barrientos-Gutierrez T, Tellez-Avila F, Soares-Weiser K, Mendez-Sanchez N, Gluud C, Uribe M.Meta-analysis: antibiotic prophylaxis for cirrhotic patients with upper gastrointestinal bleeding - an updated Cochrane review. Aliment Pharmacol Ther. 2011 Sep;34(5):509-18. doi: 10.1111/j.1365-2036.2011.04746.x. Epub 2011 Jun 27. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD
Contributor: Erik Verzemnieks, MD Educational Pearls: Knee dislocations are most common in high energy trauma, such as a motor vehicle accident The knee may appear grossly normal on initial inspection since dislocations can spontaneously reduce - Look for such findings as hemarthrosis, instability, or ecchymosis, as clues to an occult dislocation. Knee dislocations are often associated with damage to the popliteal artery that runs behind the knee. Assess for pulse deficit on exam. If you are concerned - use the ankle-brachial index (normal >0.9). If the ABI is abnormal, evaluate with CT angiogram and a vascular surgery consult. References Mills WJ, Barei DP, McNair P. The value of the ankle-brachial index for diagnosing arterial injury after knee dislocation: a prospective study. J Trauma. 2004 Jun;56(6):1261-5. Steele HL, Singh A. Vascular injury after occult knee dislocation presenting as compartment syndrome. J Emerg Med 2012; 42:271. Sillanpää PJ, Kannus P, Niemi ST, et al. Incidence of knee dislocation and concomitant vascular injury requiring surgery: a nationwide study. J Trauma Acute Care Surg 2014; 76:715. Summarized and written by myself
Contributor: Don Stader, MD Educational Pearls: The eye is surrounded by relatively inflexible tissues such as the bone of the orbit and the fibrous tissue of the eye. This makes it relatively susceptible to damage from outside compression, which is most common from trauma. This phenomenon is called ocular compartment syndrome (OCS) Look for OCS when patients have face, head or direct eye trauma OCS will present with a swollen, bulging eye associated with pain and blurry vision. Typically diagnosed with an elevated intraocular pressure (>40) OCS needs to be treated with a lateral canthotomy to help expand the area around the eye, reducing the pressure. Can’t see the eye due to swelling? Use paper clips to make eyelid retractors! References Lima V, Burt B, Leibovitch I, Prabhakaran V, Goldberg RA, Selva D. Orbital compartment syndrome: the ophthalmic surgical emergency. Surv Ophthalmol. 2009 Jul-Aug;54(4):441-9. doi: 10.1016/j.survophthal.2009.04.005. Review. PubMed PMID: 19539832. Rowh AD, Ufberg JW, Chan TC, Vilke GM, Harrigan RA. Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome. J Emerg Med. 2015 Mar;48(3):325-30. doi: 10.1016/j.jemermed.2014.11.002. Epub 2014 Dec 16. PubMed PMID: 25524455. Summarized by Will Dewispelaere, MS4 | Edited by Erik Verzemnieks, MD
Stroke is a common presentation to all Emergency Health care providers, with around 150,000 strokes occurring in the UK each year! Our impact and treatment can be hugely significant and in this podcast we’re going to conver the topic in some depth, and importantly cover some of the new Guidance published by NICE in their ‘Stroke and transient ischaemic attack in the over 16’s diagnosis and initial management’ document that was published in May of this year. We'll be running through Definition Pathophysiology Territories Risk factors Assessment; both prehospitally and in hospital Stroke mimics Investigations As always we’d love to hear any thoughts or comments you have on the website and via twitter. Enjoy! Simon, Rob & James References Stroke & Dizziness; PHEMCAST RCEMLearning; RCEM Belfast Vertigo Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. NICE guideline.Published: 1 May 2019 Acute Stroke Lecture notes; LITFL Stroke Thrombolysis; LITFL Are you at risk of a Stroke; Stroke Association Modifiable Risk Factors for Stroke and Strategies for Stroke Prevention.Hill VA. Semin Neurol. 2017 A systematic review of stroke recognition instruments in hospital and prehospital settings. Rudd M. Emerg Med J. 2016 Acute Stroke Diagnosis.Kenneth S. Yew. Am Fam Physician. 2009 Imaging of acute stroke prior to treatment: current practice and evolving techniques.G Mair. Br J Radiol. 2014 Should CT Angiography be a Routine Component of Acute Stroke Imaging?Vanja Douglas. Neuro hospitalist. 2015 Comparative Sensitivity of Computed Tomography vs. Magnetic Resonance Imaging for Detecting Acute Posterior Fossa Infarct. David Y Hwang. J Emerg Med. 2013 Posterior circulation ischaemic stroke. A Merwick BMJ 2014 Prehospital stroke scales as screening tools for early identification of stroke and transient ischemic attack (Review)Zhelev Z, Walker G, Henschke N, Fridhandler J, Yip S. 2019. Cochrane.
Vital signs are called vital for a reason. On this episode, Dr. Patrick takes us through a differential for the workup of sinus tachycardia. This is a finding that we see daily in our practice, but often lack a step-wise approach when managing these patients. REFERENCES: 1. Bossart P, Fosnocht D, Swanson E. Changes in heart rate do not correlate with changes in pain intensity in emergency department patients. J Emerg Med. 2007;32(1):19–22. 2. Marco CA, Plewa MC, Buderer N, Hymel G, Cooper J. Self-reported pain scores in the emergency department: lack of association with vital signs. Acad Emerg Med. 2006;13(9):974–979. 3. https://www.ncbi.nlm.nih.gov/pubmed/19700579
Välkommen till majavsnittet av AKUTBOKEN podcast. Här är ämnena och artiklarna i detta avsnitt: Behandling av akut hyperkalemi Long et al. (2018) Controversies in Management of Hyperkalemia. J Emerg Med. 55:192-205 PMID: 29731287 Peacock et al. (2018) Real World Evidence for Treatment of Hyperkalemia in the Emergency Department (REVEAL-ED) J Emerg Med. 55:741-750. PMID: 30391144 […]
'Patients with GCS scores of 8 or less require prompt intubation', that's what ATLS tells us. The mantra of GCS 8, intubate has pervaded teaching for those involved in the management of patients with a reduced GCS (Glasgow Coma Scale). But on reflection it would seem slightly odd that the gain or loss of a single point on the Glasgow Coma Scale could simply account for a change in the decision as to whether a patient would benefit from intubation and ventilation. So should the patient with a GCS of 9 be best managed without a definitive airway, but when that slips to 8 we should reach for the portex®? In this podcast we take a deeper look at the GCS, we have a think about the role that it was designed to perform and consider how it should best be applied to acutely ill patients when considering protecting their airway. The podcast is based upon the blog from the TEAM Course blog(Training in Emergency Airway Management), make sure to go and have a look at the post and other resources available on that site. Enjoy! Simon, Rob & James References GCS 8 intubate; TEAMcourse Advanced trauma life support (ATLS®): the ninth edition. J Trauma Acute Care Surg.2013;74(5):1363-6.Teasdale G, Jennett B. Assessment of coma and impaired consciousness. A practical scale. Lancet. 1974;2(7872):81-4. Teasdale G, Maas A, Lecky F, Manley G, Stocchetti N, Murray G.The Glasgow Coma Scale at 40 years: standing the test of time.Lancet Neurol. 2014;13(8):844-54. Duncan R, Thakore S. Decreased Glasgow Coma Scale score does not mandate endotracheal intubation in the emergency department. J Emerg Med. 2009;37(4):451-5. Green SM. Cheerio, laddie! Bidding farewell to the Glasgow Coma Scale.Ann Emerg Med. 2011;58(5):427-30. Healey C, Osler TM, Rogers FB, et al. Improving the Glasgow Coma Scale score: motor score alone is a better predictor.J Trauma. 2003;54(4):671-8. Isbister GK, Downes F, Sibbritt D, Dawson AH, Whyte IM. Aspiration pneumonitis in an overdose population: frequency, predictors, and outcomes.Crit Care Med. 2004;32(1):88-93. Adnet F, Baud F. Relation between Glasgow Coma Scale and aspiration pneumonia.Lancet. 1996;348(9020):123-4. Kulig K, Rumack BH, Rosen P. Gag reflex in assessing level of consciousness.Lancet. 1982;1(8271):565. Rotheray KR, Cheung PS, Cheung CS, et al. What is the relationship between the Glasgow coma scale and airway protective reflexes in the Chinese population?.Resuscitation. 2012;83(1):86-9. Moulton C, Pennycook A, Makower R. Relation between Glasgow coma scale and the gag reflex.BMJ. 1991;303(6812):1240-1.
Podcast # 437 : Myasthenia Gravis Author: Gretchen Hinson, MD Educational Pearls: Myasthenia gravis (MG) is an antibody mediated autoimmune disorder against the acetylcholine receptors at the neuromuscular junctions. Bimodal age distribution (20’s-30’s: women; 60’s-70’s: men) Presents with fluctuating muscle weakness typically worse at the end of the day with upper extremities affected more than lower and typically involving facial muscles. Myasthenia crisis occurs when muscle fatigue begins to cause respiratory depression MG was historically diagnosed with the Tensilon test but now often by EMG Treatment of MG crisis involves plasma exchange and IVIG. Those in crisis often require intubation and ICU admission References: Gilhus NE. Myasthenia Gravis. N Engl J Med. 2016 Dec 29;375(26):2570-2581. doi: 10.1056/NEJMra1602678. Review. PubMed PMID: 28029925. Roper J, Fleming ME, Long B, Koyfman A. Myasthenia Gravis and Crisis: Evaluation and Management in the Emergency Department. J Emerg Med. 2017 Dec;53(6):843-853. doi: 10.1016/j.jemermed.2017.06.009. Epub 2017 Sep 12. PubMed PMID: 28916122. Summarized by Travis Barlock, MS4 | Edited by Erik Verzemnieks, MD
The following is a short list of salient points related to the podcast and the corresponding source literature. As always, read the source literature and critically appraise it for yourself. Take none of the following as a substitution for local protocol or procedure. 2018 NAEMSP Spinal Immobilization paper https://naemsp.org/resources/position-statements/spinal-immobilization/ Securing a patient to the stretcher mattress significantly reduces lateral motion: Am J Emerg Med. 2016 Apr;34(4):717-21. doi: 10.1016/j.ajem.2015.12.078. Epub 2015 Dec 30. C-Collar limits visible external motion in the intact spine, but not internal motion in the unstable injured spine: Horodyski M, DiPaola CP, Conrad BP, Rechtine GR 2nd. Cervical collars are insufficient for immobilizing an unstable cervical spine injury. J Emerg Med. 2011 Nov;41(5):513-9. doi: 10.1016/j.jemermed.2011.02.001. Epub 2011 Mar 12. PubMed PMID: 21397431. C-Collar increases ICP: Davies G, Deakin C, Wilson A. The effect of a rigid collar on intracranial pressure. Injury. 1996 Nov;27(9):647-9. PubMed PMID: 9039362. C-Collar causes distraction of unstable C-spine: Ben-Galim P, Dreiangel N, Mattox KL, Reitman CA, Kalantar SB, Hipp JA. Extrication collars can result in abnormal separation between vertebrae in the presence of a dissociative injury. J Trauma. 2010 Aug;69(2):447-50. doi:10.1097/TA.0b013e3181be785a. PubMed PMID: 20093981. Lador R, Ben-Galim P, Hipp JA. Motion within the unstable cervical spine during patient maneuvering: the neck pivot-shift phenomenon. J Trauma. 2011 Jan;70(1):247-50; discussion 250-1. doi: 10.1097/TA.0b013e3181fd0ebf. PubMed PMID: 21217496. Spinal immobilization negatively impacts the physical exam: March J et al. Changes In Physical Examination Caused by Use of Spinal Immobilization. Prehosp Emerg Care 2002; 6(4): 421 – 4. PMID: 12385610 Chan D, Goldberg R, Tascone A, Harmon S, Chan L. The effect of spinal immobilization on healthy volunteers. Ann Emerg Med. 1994 Jan;23(1):48-51. PubMed PMID: 8273958. Chan D, Goldberg RM, Mason J, Chan L. Backboard versus mattress splint immobilization: a comparison of symptoms generated. J Emerg Med. 1996 May-Jun;14(3):293-8. PubMed PMID: 8782022. Even Manual In Line Stabilization alone increased difficulty during intubation and increases forces applied to the neck: Thiboutot F, Nicole PC, Trépanier CA, Turgeon AF, Lessard MR. Effect of manual in-line stabilization of the cervical spine in adults on the rate of difficult orotracheal intubation by direct laryngoscopy: a randomized controlled trial. Can J Anaesth. 2009 Jun;56(6):412-8. doi: 10.1007/s12630-009-9089-7. Epub 2009 Apr 24. PubMed PMID: 19396507. Santoni BG, Hindman BJ, Puttlitz CM, Weeks JB, Johnson N, Maktabi MA, Todd MM. Manual in-line stabilization increases pressures applied by the laryngoscope blade during direct laryngoscopy and orotracheal intubation. Anesthesiology. 2009 Jan;110(1):24-31. doi: 10.1097/ALN.0b013e318190b556. PubMed PMID: 19104166. Spinal immobilization makes it harder to breath and decreases forced expiratory volume: “...produce a significantly restrictive effect on pulmonary function in the healthy, nonsmoking man.” Chan, D., Goldberg, R., Tascone, A., Harmon, S., & Chan, L. (1994). The effect of spinal immobilization on healthy volunteers. Annals of Emergency Medicine, 23(1), 48–51. https://doi.org/10.1016/S0196-0644(94)70007-9 Schafermeyer RW, Ribbeck BM, Gaskins J, Thomason S, Harlan M, Attkisson A. Respiratory effects of spinal immobilization in children. Ann Emerg Med. 1991 Sep;20(9):1017-9. PubMed PMID: 1877767. Totten VY, Sugarman DB. Respiratory effects of spinal immobilization. Prehosp Emerg Care. 1999 Oct-Dec;3(4):347-52. PubMed PMID: 10534038. Prehospital providers can effectively apply selective immobilization criteria without causing harm: Domeier, R. M., Frederiksen, S. M., & Welch, K. (2005). Prospective performance assessment of an out-of-hospital protocol for selective spine immobilization using clinical spine clearance criteria. Annals of Emergency Medicine, 46(2), 123–131. https://doi.org/10.1016/j.annemergmed.2005.02.004 Out of 32,000 trauma encounters, a prehospital clearance protocol resulted in ONE patient with an unstable injury that was not immobilized. This patient injured her back one week prior, required fixation, but had no neurological injury: Burton, J.H., Dunn, M.G., Harmon, N.R., Hermanson, T.A., and Bradshaw, J.R. A statewide, prehospital emergency medical service selective patient spine immobilization protocol. J Trauma. 2006; 61: 161–167 Ambulatory patients self extricating with a cervical collar results in less cervical spine motion than with the use of a backboard: Shafer, J. S., & Naunheim, R. S. (2009). Cervical Spine Motion During Extrication: A Pilot Study. Western Journal of Emergency Medicine, 10(2), 74–78. https://doi.org/10.1016/j.jemermed.2012.02.082 Engsberg JR, Standeven JW, Shurtleff TL, Eggars JL, Shafer JS, Naunheim RS. Cervical spine motion during extrication. J Emerg Med. 2013 Jan;44(1):122-7. doi:10.1016/j.jemermed.2012.02.082. Epub 2012 Oct 15. PubMed PMID: 23079144 Lift and slide technique is superior to log roll: Boissy, P., Shrier, I., Brière, S. et al. Effectiveness of cervical spine stabilization techniques. Clin J Sport Med. 2011; 21: 80–88 Despite there not being any randomized control trials evaluating spinal immobilization, patients transferred to hospitals immobilized have more disability than those transported without immobilization: Hauswald, M., Ong, G., Tandberg, D., and Omar, Z. Out-of-hospital spinal immobilization: its effect on neurologic injury. Acad Emerg Med. 1998; 5: 214–219 “Mechanism of injury does not affect the ability of clinical criteria to predict spinal injury” Domeier, R.M., Evans, R.W., Swor, R.A. et al. The reliability of prehospital clinical evaluation for potential spinal injury is not affected by the mechanism of injury.Prehosp Emerg Care. 1999; 3: 332–337 Spinal immobilization in penetrating trauma is associated with an increased risk of death: Vanderlan, W.B., Tew, B.E., and McSwain, N.E. Jr. Increased risk of death with cervical spine immobilisation in penetrating cervical trauma. Injury. 2009; 40: 880–88 Stuke, L.E., Pons, P.T., Guy, J.S., Chapleau, W.P., Butler, F.K., and McSwain, N.E.Prehospital spine immobilization for penetrating trauma-review and recommendations from the Prehospital Trauma Life Support Executive Committee. J Trauma. 2011; 71: 763–769 “The number needed to treat with spine immobilization to potentially benefit one patient was 1,032. The number needed to harm with spine immobilization to potentially contribute to one death was 66.” Haut, E.R., Kalish, B.T., Efron, D.T. et al. Spine immobilization in penetrating trauma: more harm than good?. J Trauma. 2010; 68: 115–121 Vanderlan WB, Tew BE, Seguin CY, Mata MM, Yang JJ, Horst HM, Obeid FN, McSwain NE. Neurologic sequelae of penetrating cervical trauma. Spine (Phila Pa 1976). 2009 Nov 15;34(24):2646-53. doi: 10.1097/BRS.0b013e3181bd9df1. PubMed PMID: 19881402. Velopulos CG, Shihab HM, Lottenberg L, Feinman M, Raja A, Salomone J, Haut ER. Prehospital spine immobilization/spinal motion restriction in penetrating trauma: A practice management guideline from the Eastern Association for the Surgery of Trauma (EAST). J Trauma Acute Care Surg. 2018 May;84(5):736-744. doi:10.1097/TA.0000000000001764. PubMed PMID: 29283970. Use of LSB can cause sufficient pressure to create pressure ulcers in a short period of time: Cordell W:H, Hollingsworth JC, Olinger ML, Stroman SJ, Nelson DR. Pain and tissue-interface pressures during spine-board immobilization. Ann Emerg Med. 1995 Jul;26(1):31-6. PubMed PMID: 7793717. The natural progression of some C-spine injuries is to get worse, sometimes because we force them into immobilization devices, sometimes because of hypotension, vascular injury, or hypoxia, but surprisingly not because of EMS providers… Harrop JS, Sharan AD, Vaccaro AR, Przybylski GJ. The cause of neurologic deterioration after acute cervical spinal cord injury. Spine (Phila Pa 1976). 2001 Feb 15;26(4):340-6. PubMed PMID: 11224879. Reports of asymptomatic but clinically important spine injuries are, at best, dubious: McKee TR, Tinkoff G, Rhodes M. Asymptomatic occult cervical spine fracture: case report and review of the literature. J Trauma. 1990 May;30(5):623-6. Review. PubMed PMID: 2188001. Bresler MJ, Rich GH. Occult cervical spine fracture in an ambulatory patients. Ann Emerg Med. 1982 Aug;11(8):440-2. PubMed PMID: 7103163.
The Free Open Access Medical Education (FOAM) world is often obsessed with magnesium. In this show we address the use of magnesium for various applications. Magnesium for Acute Atrial Fibrillation with Rapid Ventricular Response (RVR) Bouida et al. LOw dose MAGnesium sulfate versus HIgh dose in the early management of rapid atrial fibrillation: randomised controlled double blind study. Acad Emerg Med. 2018 Jul 19. Ho KM, Sheridan DJ, Paterson T. Use of intravenous magnesium to treat acute onset atrial fibrillation: a meta-analysis. Heart. 2007;93(11):1433-40. Davey MJ, Teubner D. A randomized controlled trial of magnesium sulfate, in addition to usual care, for rate control in atrial fibrillation. Ann Emerg Med. 2005;45(4):347-53. Magnesium for Migraine Corbo J, Esses D, Bijur PE, Iannaccone R, Gallagher EJ. Randomized clinical trial of intravenous magnesium sulfate as an adjunctive medication for emergency department treatment of migraine headache. Ann Emerg Med. 2001;38(6):621–7. Bigal ME, Bordini CA, Tepper SJ, Speciali JG. Intravenous magnesium sulphate in the acute treatment of migraine without aura and migraine with aura. A randomized, double-blind, placebo-controlled study. Cephalalgia. 2002;22(5):345-53. 1Cete Y, Dora B, Ertan C, Ozdemir C, Oktay C. A randomized prospective placebo-controlled study of intravenous magnesium sulphate vs. metoclopramide in the management of acute migraine attacks in the Emergency Department. Cephalalgia. 2005;25(3):199–204. Shahrami A, Assarzadegan F, Hatamabadi HR, Asgarzadeh M, Sarehbandi B, Asgarzadeh S. Comparison of therapeutic effects of magnesium sulfate vs. dexamethasone/metoclopramide on alleviating acute migraine headache. J Emerg Med. 2015;48(1):69–76. Orr SL, Friedman BW, Christie S, Minen MT, Bamford C, Kelley NE, et al. Management of Adults with Acute Migraine in the Emergency Department: The American Headache Society Evidence Assessment of Parenteral Pharmacotherapies. Headache. 2016;56(6):911–40. Magnesium for Acute Asthma Exacerbation Griffiths B, Kew KM. Intravenous magnesium sulfate for treating children with acute asthma in the emergency department. Cochrane Database Syst Rev. 2016;4:CD011050. Kew KM, Kirtchuk L, Michell CI. Intravenous magnesium sulfate for treating adults with acute asthma in the emergency department. Cochrane Database Syst Rev. 2014;(5):CD010909. Thanks for listening! Jeremy Faust and Lauren Westafer
There is nothing mysterious about the chemistry of the cerebrospinal fluid. Cells. Protein. Glucose. But the interplay of these unique components can give you incredible insight into the state of the central nervous system. This week, we revisit a prior episode where Dr. Mike Rubenstein reviews his approach to interpreting CSF results. And then we have an update at the end regarding recent advances in CSF analysis. Produced by James E. Siegler and Michael Rubenstein. Music by Steve Combs. Sound effects by Mike Koenig, Daniel Simion. Voiceover by Patrick Green (German). BrainWaves' podcasts and online content are intended for medical education only and should not be used for clinical decision making. If you like what you hear, let us know and rate the show! REFERENCES 1. Frederiks JA and Koehler PJ. The first lumbar puncture. J Hist Neurosci. 1997;6:147-53. 2. Seehusen DA, Reeves MM and Fomin DA. Cerebrospinal fluid analysis. Am Fam Physician. 2003;68:1103-8. 3. Shah KH and Edlow JA. Distinguishing traumatic lumbar puncture from true subarachnoid hemorrhage. J Emerg Med. 2002;23:67-74. 4. Deisenhammer F, Bartos A, Egg R, Gilhus NE, Giovannoni G, Rauer S, Sellebjerg F and Force ET. Guidelines on routine cerebrospinal fluid analysis. Report from an EFNS task force. European journal of neurology : the official journal of the European Federation of Neurological Societies. 2006;13:913-22. 5. Nagel MA, Cohrs RJ, Mahalingam R, Wellish MC, Forghani B, Schiller A, Safdieh JE, Kamenkovich E, Ostrow LW, Levy M, Greenberg B, Russman AN, Katzan I, Gardner CJ, Hausler M, Nau R, Saraya T, Wada H, Goto H, de Martino M, Ueno M, Brown WD, Terborg C and Gilden DH. The varicella zoster virus vasculopathies: clinical, CSF, imaging, and virologic features. Neurology. 2008;70:853-60. 6. Messacar K, Schreiner TL, Van Haren K, Yang M, Glaser CA, Tyler KL and Dominguez SR. Acute flaccid myelitis: A clinical review of US cases 2012-2015. Annals of neurology. 2016;80:326-38.
Head injury worldwide is a significant cause of morbidity and mortality. Besides prevention there isn't anything that can be done to improve the results from the primary brain injury, there is however a phenomenal amount that can be done to reduce the secondary brain injury that patients suffer, both from a prehospital and in hospital point of view. In the podcast we run through head injuries, all the way from initial classification and investigation, to specifics of treatment including neuro protective anaesthesia and hyperosmolar therapy, to give a sound overview of the management of these patients. As always we welcome feedback via the website or on Twitter and we look forward to hearing from you. Enjoy! Simon, Rob & James References & Further Reading Risk of Delayed Intracranial Hemorrhage in Anticoagulated Patients with Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis. Chauny JM. J Emerg Med. Jul 26 2016 Mannitol or hypertonic saline in the setting of traumatic brain injury: What have we learned? Boone MD. Surg Neurol Int. 2015 Life in the fast lane; hypertonic saline Life in the fast lane; Traumatic brain injury Traumatic brain injury in England and Wales: prospective audit of epidemiology, complications and standardised mortality. T Lawrence. BMJ Open. 2016 Epidemiology of traumatic brain injuries in Europe: a cross-sectional analysis. M.Majdan. The Lancet. 2016 The inefficiency of plain radiography to evaluate the cervical spine after blunt trauma. Gale SC. J Trauma. 2005 What is the relationship between the Glasgow coma scale and airway protective reflexes in the Chinese population? Rotheray KR. Resuscitation. 2012 NICE Head Injury Guidelines 2014 MDCALC Canadian Head Injury TheResusRoom; The AHEAD Study TheResusRoom; Anticoagulation, head injury & delayed bleeds Management of Perceived Devastating Brain Injury After Hospital Admission; A consensus statement A case for stopping the early withdrawal of life sustaining therapies in patients with devastating brain injuries. Manara AR. J Intensive Care Soc. 2016
(*Hypothetical Case) A 26 yr old woman with a suspected ruptured ectopic pregnancy is rushed to theatre in haemorrhagic shock. The patient has a history of IVDU with a naltrexone implant. The team in the emergency department have been unable to get vascular access. She has a heart rate of 150/min and a BP of 75/45. She is now very distressed and unco-operative from both the abdominal pain but also the repeated painful attempts at vascular access with large needles by lots of different healthcare staff! Join Graeme and I as we discuss the various different options for gaining vascular access to allow resuscitation, but also induction of anaesthesia so definitive surgery can occur. We discuss the following various options: USS guided peripheral IV access Intraosseous drills External Jugular peripheral IV cannulation Internal Jugular peripheral IV cannulation - "The Rapid IJ" Large bore central cannulation (eg MAC line, swan sheath, haemodialysis catheters) - usually Internal jugular (IJ) and subclavian (SC) or Femoral. Surgical cut-down - saphenous or brachial. Graeme even discloses that he has trialled unsuccessful sternal intraosseous placement in the past - sounds like an interesting case we should perhaps delve into more detail on at another time!! Hagen-Pouseille Equation: Bottom line - shorter and wider bore catheters are better for rapid fluid resuscitation. The MAC line - note swan sheath, haemodialysis or other large bore central catheters will also work: Youtube / Podcasts Discussing this topic: https://theprocedurescourse.com/blog/ A great course to learn emergency procedures for use in trauma care run by the critical care trauma team at The Alfred in Melbourne. Check out their description of vascular access in particular their detailed description of the technique for emergent placement of the large bore MAC line in the subclavian vein. 2. https://emcrit.org/pulmcrit/hemodynamic-access-for-the-crashing-patient-the-dirty-double/ A great discussion on the placement of large bore femoral catheters. 3. The Rapid IJ - Ultrasound guided placement of a peripheral iv cannula in the internal jugular. https://youtu.be/FjSmbUWXznY References A novel "shrug technique" for totally implantable venous access devices via the external jugular vein: A consecutive series of 254 patients. Kagawa T, et al. J Surg Oncol. 2017 Mar;115(3):291-295. doi: 10.1002/jso.24504. Epub 2016 Nov 4. The intraosseous have it: A prospective observational study of vascular access success rates in patients in extremis using video review. J Trauma Acute Care Surg. 2018 Apr;84(4):558-563. Safety and Efficacy of the "Easy Internal Jugular (IJ)": An Approach to Difficult Intravenous Access. Moayedi S, et al. J Emerg Med. 2016 Dec;51(6):636-642. doi: 10.1016/j.jemermed.2016.07.001. Epub 2016 Sep 19. QUIZ 2 These are ABG's from four different individuals? What do these represent? First correct answer gets kudos and a mention on the next podcast!
Comfortable with G-tubes, tracheostomies, and VP shunts? Good. Get ready for the next level: Vagus Nerve Stimulators, Intrathecal Pumps, and Ventricular Assist Devices. Details in Audio: Vagus Nerve Stimulators For intractable epilepsy; sends retrograde signal up corona radiata Also may be used in: depression, bulimia, Alzheimer, narcolepsy, addiction, and others VNS magnets Are VNS safe in MRI? Are VNS safe in everyday life? Intrathecal Pumps Used to infuse basal rate of drug, usually baclofen for spasticity, but pump may contain morphine, bupivicaine, clonidine. Also used for severe MS, stroke, TBI, chronic pain. Verify the medication and identify the toxidrome if symptomatic. Ventricular Assist Devices May be left ventricular assist, right ventricular assist, or biventricular assist device. References Vagus Nerve Stimulators (VNS) Elliott RE, Rodgers SD, Bassani L et al. Vagus nerve stimulation for children with treatment-resistant epilepsy: a consecutive series of 141 cases. J Neurosurg Pediatrics. 2011; 7:491-500. Groves DA, Brown VJ. Vagal nerve stimulation: a review of its applications and potential mechanisms that mediate its clinical effects. Neuroscience and Biobehavioral Reviews. 2005; 29: 493–500. Panebianco M, Rigby A,Weston J,Marson AG. Vagus nerve stimulation for partial seizures. Cochrane Database of Systematic Reviews. 2015; 4, Art. No.: CD002896. Ruffoli R, Giorgi FS, Pizzanelli C et al. The chemical neuroanatomy of vagus nerve stimulation. Journal of Chemical Neuroanatomy; 2011; 42: 288–296. Intrathecal Pumps Borowski A, Littleton AG, Borkhuu B et al. Complications of Intrathecal Baclofen Pump Therapy in Pediatric Patients. J Pediatr Orthop. 2010; 30:76–81. Ghosh D, Mainali G, Khera J, Luciano M. Complications of Intrathecal Baclofen Pumps in Children: Experience from a Tertiary Care Center. Pediatr Neurosurg. 2013; 49:138–144. Yang TF, Wang JC, Chiu JW et al. Ultrasound-guided refilling of an intrathecal baclofen pump—a case report. Childs Nerv Syst. 2013; 29:347–349. Yeh RN, Nypaver MM, Deegan TJ, Ayyangar R. Baclofen Toxicity in an 8-year-old with an Intrathecal Baclofen Pump. J Emerg Med. 2004; 26(4): 163–167. Ventricular Assist Devices Blume ED, Naftel DC, Bastardi HJ et al. for the Pediatric Heart Transplant Study Investigators. Outcomes of Children Bridged to Heart Transplantation With Ventricular Assist Devices: A Multi-Institutional Study. Circulation. 2006; 113: 2313-2319. Colón JE, Laborde ME, Nossaman BD. Case Report: Left Ventricular Assist Device in a 12 Year Old Child as a Bridge to Heart Transplantation. Section of Congenital Cardiac Anesthesia, Ochsner Medical Center, New Orleans, Louisiana. 2012. Fan Y, Weng YG, Huebler M et al. Predictors of In-Hospital Mortality in Children After Long-Term Ventricular Assist Device Insertion. J Amer Coll Cardiol. 2011; 58(11):1183–90 Fraser CD, Jaquiss RDB, Rosenthal DN et al. Prospective Trial of a Pediatric Ventricular Assist Device. N Engl J Med. 2012;367:532-41. Gazit AZ, Gandhi SK, Canter CC. Mechanical Circulatory Support of the Critically Ill Child Awaiting Heart Transplantation. Current Cardiology Reviews. 2010; 6: 46-53. VanderPluym CJ, Fynn-Thompson F, Blume ED. Ventricular Assist Devices in Children Progress With an Orphan Device Application. Circulation. 2014;129:1530-1537. This post and podcast are dedicated to Joe Bellezzo, MD, FACEP and Zack Shinar, MD, FACEP for bringing us all up to speed. Listen to their fantastic ED ECMO podcast here.
Abdominal pain is common; so are strongly held myths and legends about what is concerning, and what is not. One of our largest responsibilities in the Emergency Department is sorting out benign from surgical or medical causes of abdominal pain. Morbidity and mortality varies by age and condition. Abdominal Surgical Emergencies in Children: A Relative Timeline General Advice Neonate (birth to one month) Necrotizing Enterocolitis Pneumatosis Intestinalis. Essentials: Typically presents in 1st week of life (case reports to 6 months in chronically ill children) Extend suspicion longer in NICU graduates Up to 10% of all cases of necrotizing enterocolitis are in full-term children Pathophysiology is unknown, but likely a translocation of bacteria Diagnosis: Feeding intolerance, abdominal distention Abdominal XR: pneumatosis intestinalis Management: IV access, NG tube, broad-spectrum antibiotics, surgery consult, ICU admission Intestinal Malrotation with Volvulus Essentials: Corkscrew Sign in Malrotation with Volvulus Bilious vomiting (80-100%) in the 1st month; especially in the 1st week May look well initially, then rapidly present in shock Ladd’s bands: abnormally high tethering of cecum to abdominal wall; peristalsis, volvulus, ischemia Diagnosis: History of bilious emesis is sufficient to involve surgeons Upper GI series: corkscrew appearance US (if ordered) may show abnormal orientation of and/or flow to superior mesenteric artery and vein Management: Stat surgical consult IV access, resuscitation, NG tube to decompress (bowel wall perfusion at risk, distention worsens) Hirschprung Disease Essentials: Problem in migration of neural crest cells Aganglionic colon (80% rectosigmoid; 15-20% proximal to sigmoid; 5% total colonic aganglionosis) colon (known as short-segment disease) Poor to no peristalsis: constipation, perforation, and/or sepsis Diagnosis: May be diagnosed early as “failure to pass meconium in 1st 48 hours” In ED, presents as either bowel obstruction or enterocolitis Contrast enema Beware of the toxic megacolon (vomiting, distention, sepsis) Management: Resuscitation, antibiotics, NG tube decompression, surgical consultation; stable patients may need rectal biopsy for confirmation Staged surgery (abdominoperineal pull-through with diverting colostomy, subsequent anastomosis) versus one-stage repair. Infant and Toddler (1 month to 2 years) Pyloric Stenosis Essentials: Hypertrophy of pyloric sphincter; genetic, environmental, exposure factorsString Sign in Pyloric Stenosis. Diagnosis: Hungry, hungry, not-so-hippos; they want to eat all of the time, but cannot keep things down Poor weight gain (less than 20-30 g/day) US: “π–loric stenosis” (3.14); pylorus dimensions > 3 mm x 14 mm UGI: “string sign” Management: Trial of medical treatment with oral atropine via NGT (muscarinic effects decrease pyloric tone) Ramstedt pyloromyotomy (definitive) Intussusception Essentials: Majority (90%) ileocolic; no pathological lead point Small minority (4%) ileoileocolic due to lead point: Meckel’s diverticulum, polyp, Peyer’s patches, Henoch-Schönlein purpura (intestinal hematoma) Diagnosis: Target Sign (Donut Sign). Ultrasound sensitivity and specificity near 100% in experienced hands Abdominal XR may show non-specific signs; used mainly to screen for perforation before reduction Management: Hydrostatic enema: contrast (barium or water-soluble contrast with fluoroscopy) or saline (with ultrasound) Air-contrast enema: air or carbon dioxide (with either fluoroscopy or ultrasound); higher risk for perforation than hydrostatic (1% risk), but generally safer than perforation from contrast Consider involving surgical service early (precaution before reduction) Traditional disposition is admission; controversial: home discharge from ED Young Child and Older (2 years and up) Appendicitis Essentials: Appendicitis occurs in all ages, but rarer in infants. Infants do not have fecalith; rather they have some other anatomic or congenital condition. More common in school-aged children (5-12 years) and adolescents Younger children present atypically, more likely to have perforated when diagnosed. Diagnosis: Non-specific signs and symptoms Often have abdominal pain first; vomiting comes later Location/orientation of appendix varies Appendicitis scores vary in their performance Respect fever and abdominal pain Management: Traditional: surgical On the horizon: identification of low-risk children who may benefit from trial of antibiotics If perforated, interval appendectomy (IV antibiotics via PICC for 4-6 weeks, then surgery) Obstruction SBO. Incarcerated Inguinal Hernia. Essentials: Same pathophysiology and epidemiology as adults: “ABC” – adhesions, “bulges” (hernias), and cancer. Diagnosis: Obstruction is a sign of another condition. Look for cause of obstruction: surgical versus medical Abdominal XR in low pre-test probability CT abdomen/pelvis for moderate-to-high risk; confirmation and/or surgical planning Management: Treat underlying cause NG tube to low intermittent wall suction Admission, fluid management, serial examinations Take these pearls home: Consider surgical pathology early in encounter Resuscitate while you investigate Have a low threshold for imaging and/or consultation, especially in preverbal children Selected References Necrotizing Enterocolitis Neu J, Walker A. Necrotizing Enterocolitis. N Eng J Med. 2011; 364(3):255-264. Niño DF et al. Necrotizing enterocolitis: new insights into pathogenesis and mechanisms. Nature. 2016; 13:590-600. Walsh MC et al. Necrotizing Enterocolitis: A Practitioner’s Perspective. Pediatr Rev. 1988; 9(7):219-226. Malrotation with Midgut Volvulus Applegate KE. Intestinal Malrotation in Children: A Problem-Solving Approach to the Upper Gastrointestinal Series. Radiographics. 2006; 26:1485-1500. Kapfer SA, Rappold JF. Intestinal Malrotation – Not Just the Pediatric Surgeon’s Problem. J Am Coll Surg. 2004; 199(4):628-635. Lee HC et al. Intestinal Malrotation and Catastrophic Volvulus in Infancy. J Emerg Med. 2012; 43(1):49-51. Martin V, Shaw-Smith C. Review of genetic factors in intestinal malrotation. Pediatr Surg Int. 2010; 26:769-781. Nehra D, Goldstein AM. Intestinal malrotation: Varied clinical presentation from infancy through adulthood. Surgery. 2010; 149(3):386-391. Hirschprung Disease Amiel J, Sproat-Emison E, Garcia-Barcelo M, et al. Hirschsprung disease, associated syndromes and genetics: a review. J Med Genet 2008; 45:1. Arshad A, Powell C, Tighe MP. Hirschsprung's disease. BMJ 2012; 345:e5521. Aworanti OM, McDowell DT, Martin IM, Quinn F. Does Functional Outcome Improve with Time Postsurgery for Hirschsprung Disease? Eur J Pediatr Surg 2016; 26:192. Clark DA. Times of first void and first stool in 500 newborns. Pediatrics 1977; 60:457. Dasgupta R, Langer JC. Evaluation and management of persistent problems after surgery for Hirschsprung disease in a child. J Pediatr Gastroenterol Nutr 2008; 46:13. De Lorijn F, Reitsma JB, Voskuijl WP, et al. Diagnosis of Hirschsprung's disease: a prospective, comparative accuracy study of common tests. J Pediatr 2005; 146:787. Doig CM. Hirschsprung's disease and mimicking conditions. Dig Dis 1994; 12:106. Khan AR, Vujanic GM, Huddart S. The constipated child: how likely is Hirschsprung's disease? Pediatr Surg Int 2003; 19:439. Singh SJ, Croaker GD, Manglick P, et al. Hirschsprung's disease: the Australian Paediatric Surveillance Unit's experience. Pediatr Surg Int 2003; 19:247. Suita S, Taguchi T, Ieiri S, Nakatsuji T. Hirschsprung's disease in Japan: analysis of 3852 patients based on a nationwide survey in 30 years. J Pediatr Surg 2005; 40:197. Sulkowski JP, Cooper JN, Congeni A, et al. Single-stage versus multi-stage pull-through for Hirschsprung's disease: practice trends and outcomes in infants. J Pediatr Surg 2014; 49:1619. Pyloric Stenosis Aspelund G, Langer JC. Current management of hypertrophic pyloric stenosis. Semin Pedaitr Surg. 2007; 16:27-33. Dias SC et al. Hypertrophic pyloric stenosis: tips and tricks for ultrasound diagnosis. Insights Imaging. 2012; 3:247-250. Kawahara H et al. Medical treatment of infantile hypertrophic pyloric stenosis: should we always slice the olive? J Pediatr Surg. 2005; 40:1848-1851. Mack HC. Adult Hypertrophic Pyloric Stenosis. Arch Inter Med. 1959; 104:78-83. Meissner PE et al. Conservative treatment of infantile hypertrophic pyloric stenosis with intravenous atropine sulfate does not replace pyloromyotomy. Pediatr Surg Int. 2006; 22:1021-1024. Mercer AE, Phillips R. Can a conservative approach to the treatment of hypertrophic pyloric stenosis with atropine be considered a real alternative to pyloromyotomy? Arch Dis Child. 2013; 95(6): 474-477. Pandya S, Heiss K, Pyloric Stenosis in Pediatric Surgery.Surg Clin N Am. 2012; 92:527-39. Peters B et al. Advances in infantile hypertrophic pyloric stenosis. Expert Rev Gastroenterol Hepatol. 2014; 8(5):533-541. Intussusception Apelt N et al. Laparoscopic treatment of intussusception in children: A systematic review. J Pediatr Surg. 2013; 48:1789-1793. Applegate KE. Intussusception in Children: Imaging Choices. Semin Roentgenol. 2008; 15-21. Bartocci M et al. Intussusception in childhood: role of sonography on diagnosis and treatment. J Ultrasound. 2015; 18 Gilmore AW et al. Management of childhood intussusception after reductiion by enema. Am J Emerg Med. 2011; 29:1136-1140.:205-211. Chien M et al. Management of the child after enema-reduced intussusception: hospital or home? J Emerg Med. 2013; 44(1):53-57. Cochran AA et al. Intussusception in traditional pediatric, nontraditional pediatric, and adult patients. Am J Emerg Med. 2011; 523-527. Loukas M et al. Intussusception: An Anatomical Perspective With Review of the Literature. Clin Anatomy. 2011; 24: 552-561. Mendez D et al. The diagnostic accuracy of an abdominal radiograph with signs and symptoms of intussusception. Am J Emerg Med. 2012; 30:426-431. Whitehouse et al. Is it safe to discharge intussusception patients after successful hydrostatic reduction? J Pediatr Surg. 2010; 45:1182-1186. Appendicitis Amin P, Chang D. Management of Complicated Appendicitis in the Pediatrc Population: When Surgery Doesn’t Cut it. Semin Intervent Radiol. 2012; 29:231-236 Blakely ML et al. Early vs Interval Appendectomy for Children With Perforated Appendicitis. Arch Surg. 2011; 146(6):660-665. Bundy DG et al. Does This Child Have Appendicitis? JAMA. 2007; 298(4):438-451. Cohen B et al. The non-diagnostic ultrasound in appendicitis: is a non-visualized appendix the same as a negative study? J Pediatr Surg. 2015 Jun;50(6):923-7 Herliczek TW et al. Utility of MRI After Inconclusive Ultrasound in Pediatric Patients with Suspected Appendicitis. AJT. 2013; 200:969-973. Janitz et al. Ultrasound Evaluation for Appendicitis. J Am Osteopath Coll Radiol. 2016; 5(1):5-12. Kanona H et al. Stump Appendicitis: A Review. Int J Surg. 2012; 10:4255-428. Kao LS et al. Antibiotics vs Appendectomy for Uncomplicated Acute Appendicitis. Evid Based Rev Surg. 2013;216(3):501-505. Petroianu A. Diagnosis of acute appendicitis. Int J Surg. 2012; 10:115-119. Mazeh H et al. Tip appendicitis: clinical implications and management. Amer J Surg. 2009; 197:211-215. Puig S et al. Imaging of Appendicitis in Children and Adolescents. Semin Roentgenol. 2008; 22-28. Schizas AMP, Williams AB. Management of complex appendicitis. Surgery. 2010; 28(11):544-548. Shogilev DJ et al. Diagnosing Appendicitis: Evidence-Based Review. West J Emerg Med. 2014; 15(4):859-871. Wray CJ et al. Acute Appendicitis: Controversies in Diagnosis and Management. Current Problems in Surgery. 2013; 50:54-86 Intestinal Obstruction Babl FE et al. Does nebulized lidocaine reduce the pain and distress of nasogastric tube insertion in young children? A randomized, double-blind, placebo-controlled trial. Pediatrics. 2009 Jun;123(6):1548-55 Chinn WM, Zavala DC, Ambre J. Plasma levels of lidocaine following nebulized aerosol administration. Chest 1977;71(3):346-8. Cullen L et al. Nebulized lidocaine decreases the discomfort of nasogastric tube insertion: a randomized, double-blind trial. Ann Emerg Med. 2004 Aug;44(2):131-7. Gangopadhyay AN, Wardhan H. Intestinal obstruction in children in India. Pediatr Surg Int. 1989; 4:84-87. Hajivassiliou CA. Intestinal Obstruction in Neonatal/Pediatric Surgery. Semin Pediatr Surg. 2003; 12(4):241-253. Hazra NK et al. Acute Intestinal Obstruction in children: Experience in a Tertiary Care Hospital. Am J Pub Health Res. 2015; 3(5):53-56. Kuo YW et al. Reducing the pain of nasogastric tube intubation with nebulized and atomized lidocaine: a systematic review and meta-analysis. J Pain Symptom Manage. 2010 Oct;40(4):613-20. . Pediatric Surgery Irish MS et al. The Approach to Common Abdominal Diagnoses in Infants and Children. Pedaitr Clin N Am. 1998; 45(4):729-770. Louie JP. Essential Diagnosis of Abdominal Emergencies in the First Year of Life. Emerg Med Clin N Am. 2007; 25:1009-1040. McCullough M, Sharieff GQ. Abdominal surgical emergencies in infants and young children. Emerg Med Clin N Am. 2003; 21:909-935. Pepper VK et al. Diagnosis and Management of Pediatric Appendicitis, Intussusception, and Meckel Diverticulum. Surg Clin N Am. 2012 This post and podcast are dedicated to Mr Ross Fisher for his passion and spirit of collaboration in all things #FOAMed. Thank you, sir!
This week we discuss the identification, prevention and treatment of local anesthetic systemic toxicity. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_95_0_Final_Cut.m4a Download 6 Comments Tags: Antidote, Bupivicaine, Intralipid, Lidocaine, Toxicology Show Notes LITFL: Local Anesthetic Toxicity Wiki EM: Local Anesthetic Systemic Toxicity References: Schwartz DR, Kaufman B. Local Anesthetics. In: Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. eds. Goldfrank's Toxicologic Emergencies, 10e New York, NY: McGraw-Hill; 2015. Link Neal JM et al, American Society of Regional Anesthesia and Pain Medicine. American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med 2012;37:16–8. PMID: 22189574 Cao D et al. Intravenous lipid emulsion in the emergency department: a systematic review. J Emerg Med 2015; 48(3): 387-97. PMID:
This week we discuss the identification, prevention and treatment of local anesthetic systemic toxicity. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_95_0_Final_Cut.m4a Download 6 Comments Tags: Antidote, Bupivicaine, Intralipid, Lidocaine, Toxicology Show Notes LITFL: Local Anesthetic Toxicity Wiki EM: Local Anesthetic Systemic Toxicity References: Schwartz DR, Kaufman B. Local Anesthetics. In: Hoffman RS, Howland M, Lewin NA, Nelson LS, Goldfrank LR. eds. Goldfrank’s Toxicologic Emergencies, 10e New York, NY: McGraw-Hill; 2015. Link Neal JM et al, American Society of Regional Anesthesia and Pain Medicine. American Society of Regional Anesthesia and Pain Medicine checklist for managing local anesthetic systemic toxicity: 2012 version. Reg Anesth Pain Med 2012;37:16–8. PMID: 22189574 Cao D et al. Intravenous lipid emulsion in the emergency department: a systematic review. J Emerg Med 2015; 48(3): 387-97. PMID: 25534900
Children the world over are fascinated with what can possibly “fit” in their orifices. Diagnosis is often delayed. Anxiety abounds before and during evaluation and management. Most common objects:1,2 Food Coins Toys Insects Balls, marbles Balloons Magnets Crayon Hair accessories, bows Beads Pebbles Erasers Pen/marker caps Button batteries Plastic bags, packaging Non-pharmacologic techniques Set the scene and control the environment. Limit the number of people in the room, the noise level, and minimize “cross-talk”. The focus should be on engaging, calming, and distracting the child. Quiet room; calm parent; “burrito wrap”; guided imagery; have a willing parent restrain the child in his or her lap – an assistant can further restrain the head. Procedural Sedation Most foreign bodies in the ear, nose, and throat in children can be managed with non-pharmacologic techniques, topical aids, gentle patient protective restraint, and a quick hand. Consider sedation in children with special health care needs who may not be able to cooperate and technically delicate extractions. Ketamine is an excellent agent, as airway reflexes are maintained.3 Remember to plan, think ahead: where could the foreign body may be displaced if something goes wrong? You may have taken away his protective gag reflex with sedation. Position the child accordingly to prevent precipitous foreign body aspiration or occlusion. L’OREILLE – DAS OHR – вухо – THE EAR – LA OREJA – 耳 – L'ORECCHIO Essential anatomy: The external auditory canal. Foreign bodies may become lodged in the narrowing at the bony cartilaginous junction.4 The lateral 1/3 of the canal is flexible, while the medial 2/3 is fixed in the temporal bone – here is where many foreign bodies are lodged and/or where the clinician may find evidence of trauma. Pearls: Ask yourself: is it graspable or non-graspable?5 Graspable: 64% success rate, 14% complication rate Non-graspable: 45% success rate, 70% complication rate5 If there is an insect in the external auditory canal, kill it first. They will fight for their lives if you try to dismember or take them out. “In the heat of battle, the patient can become terrorized by the noise and pain and the instrument that you are using is likely to damage the ear canal.”5,6 Use lidocaine jelly (preferred), viscous lidocaine (2%), lidocaine solution (2 or 4%), isopropyl alcohol, or mineral oil. Vegetable matter? Don’t irrigate it – the organic material will swell against the fixed structure, and cause more pain, make it much harder to extract, and may increase the risk of infection. Pifalls: Failure to inspect after removal – is there something else in there? Failure to assess for abrasions, trauma, infection – if any break in skin, give prophylactic antibiotic ear drops Law of diminishing returns: probability of successful removal of ear foreign bodies declines dramatically after the first attempt LE NEZ – DIE NASE – ніс – THE NOSE – LA NARIZ – 鼻 – IL NASO Essential anatomy: Nasopharyngeal and tracheal anatomy. Highlighted areas indicate points at which nasal foreign bodies may become lodged.4 Pearls: Consider using topical analgesics and vasoconstrictors to reduce pain and swelling – and improve tolerance of/cooperation with the procedure. Use 0.5% oxymetolazone (Afrin) spray and a few drops of 2 or 4% Pros: as above. Cons: possible posterior displacement of the foreign body.7 Be ready for the precipitous development of an airway foreign body Pitfalls: Beware of unilateral nasal discharge in a child – strongly consider retained foreign body.8 Do not push a foreign body down the back of a patient's throat, where it may be aspirated into the trachea. Be sure to inspect the palate for “vacuum effect”: small or flexible objects may be found on the roof of the mouth, just waiting to be aspirated. LA GORGE – DER HALS – горло – THE THROAT – LA GARGANTA – 喉 – LA GOLA Before we go further – Remember that a foreign body in the mouth or throat can precipitously become a foreign body in the airway. Foreign body inhalation is the most common cause of accidental death in children less than one year of age.9,10 Go to BLS maneuvers if the child decompensates. Infants under 1 year of age – back blows: head-down, 5 back-blows (between scapulae), 5 chest-thrusts (sternum). Reassess, repeat as needed. Children 1 year and up, conscious – Heimlich maneuver: stand behind patient with arms positioned under the patient’s axilla and encircling the chest. The thumb side of one fist should be placed on the abdomen below the xiphoid process. The other hand should be placed over the fist, and 5 upward-inward thrusts should be performed. This maneuver should be repeated if the airway remains obstructed. Alternatively, if patient is supine, open the airway, and if the object is readily visible, remove it. Abdominal thrusts: place the heel of one hand below the xiphoid, interlace fingers, and use sharp, forceful thrusts to dislodge. Be ready to perform CPR. Children 1 year and up, unconscious – CPR: start CPR with chest compressions (do not perform a pulse check). After 30 chest compressions, open the airway. If you see a foreign body, remove it but do not perform blind finger sweeps because they may push obstructing objects further into the pharynx and may damage the oropharynx. Attempt to give 2 breaths and continue with cycles of chest compressions and ventilations until the object is expelled. Chest films are limited: 80% of airway foreign bodies are radiolucent.11 Look for unilateral hyperinflation on expiratory films: air trapping. Essential anatomy: Most esophageal foreign bodies in children occur at the level of the thoracic inlet / cricopharyngeus muscle (upper esophageal sphincter). Other anatomically narrow sites include the level of the aortic arch and the lower esophageal sphincter. Coin en face – in the esophagus – lodged at the thoracic inlet.12 The pliable esophagus accommodates the flat coin against the flat aspect of the vertebra.11 Beware the “double-ring” sign: this is a button battery13 This is an emergency: the electrolyte-rich mucosa conducts a focal current from the narrow negative terminal of the battery, rapidly causing burn, necrosis, and possibly perforation. Emergent removal is required. Button batteries that have passed into the stomach do not require emergent intervention – they can be followed closely. Not a button battery, not a sharp object, not a long object? If there is no obstruction, consider revaluation the next day – may wait up to 24 hours for passage.14 Sharieff et al.15 found that coins found in the mid to distal esophagus within 24 hours all passed successfully. What conditions prompt urgent removal? Size Infants: objects smaller than 2 cm wide and 3 cm long will likely pass the pylorus and ileocecal valve10 Children and adults: objects smaller than 2 cm wide and 5 cm long will likely pass the pylorus and ileocecal valve9 Character Sharp objects have a high rate of perforation (35%)1 Pearls: History is essential. Believe the parents and assume there is an aspirated/ingested foreign body until proven otherwise. History of choking, has persistent symptoms and/or abnormal xray? Broncoscopy! Cohen et al.16 found that of 142 patients evaluated at a single site university hospital, 61 had a foreign body. Of the 61 patients, 42 had abnormal physical exams and radiographs and 17 had either abnormal physical exams or radiographs, and 2 had normal physical exams and radiographs, but both had a history of persistent cough. Bottom line: history of choking PLUS abnormal exam, abnormal films, or persistent symptoms, evaluate with bronchoscopy. For patients with some residual suspicion of an aspirated foreign body (mild initial or improving symptoms; possibly abnormal chest x-ray; low but finite risk), consider chest CT with virtual bronchoscopy as a rule-out strategy.17,18 Outpatients who have passed a small and non-concerning object into the stomach or beyond: serial exams and observing stools – polyethylene glycol 3350 (MiraLAX) may be given for delayed passage19 Pifalls: A single household magnet will likely pass through the GI tract, with the aforementioned dimensional caveats. Two or more magnets, however, run the risk of attraction and trans-bowel wall pressure necrosis. Not all magnets are created equal. Neodymium magnet toys (“buckyballs”) were recalled in 2014 (but are still out there!) due to their highly attractive nature. These magnets must be removed to avoid bowel wall ischemia. 19–21 Patients should avoid wearing belt buckles or metallic buttons in case of single magnet ingestion while waiting for the single magnet to pass DES OUTILS DU MÉTIER – DIE HANDWERKSZEUG – Знаряддя праці – TOOLS OF THE TRADE – LAS HERRAMIENTAS DEL OFICIO – GLI ATTREZZI DEL MESTIERE – 仕事のツール It’s best to keep your armamentarium as large as you can. Curette A small foreign body in the lateral 1/3 of the auditory canal may be amenable to a simple curettage. Hair beads (if the central hole is accessible) may be manipulated out with the angled tip of a rigid curette. Steady the operating hand by placing your hypothenar eminence on the child’s zygoma or temporal scalp, to avoid jutting the instrument into the ear canal with sudden movement. There is a large selection of disposable simple and lighted curettes on the market. Right-angle Hook Various eponymous hooks are available for this purpose; one in popular use is the Day hook, which may be passed behind the foreign body.22 An inexpensive and convenient alternative to the commercially available right-hooks is a home-made version: make your own by straightening out a paperclip and bending it to a right angle23 at 2-3 mm from the end (be sure not to use the type that have a friable shiny metallic finish, as the residue may be left behind in the ear canal). If it is completely lodged, use of a right-angle hook will likely only cause trauma to the canal. Alligator forceps Alligator forceps are best for grasping soft objects like cotton or paper. Smooth, round or oval objects are not amenable to extraction with alligator forceps. When using them, be sure to get a firm, central grip on the object, to avoid tearing it into smaller, less manageable pieces. Pro tip: Look before you grip! Be careful to visualize the area you are gripping, to avoid pulling on (and subsequently avulsing) soft tissue in the ear canal. Cyanoacrylate (Dermabond®, SurgiSeal®) Apply cyanoacrylate to either side of a long wooden cotton swab (the lecturer prefers the cotton tip side, for improved grip/molding around object). Immediately apply the treated side to the object in the ear canal in a restrained patient. Steady the hypothenar eminence on the child’s face to avoid dislodgement of the cotton swab with sudden movement. Apply the treated swab to the foreign body for 30-60 seconds, to allow bonding. Slowly pull out the foreign body. Re-visualize the ear canal for other retained foreign bodies and abrasion or ear canal trauma. Did the cyanoacrylate drip? Did the swab stick to the ear canal? No problem – use 3% hydrogen peroxide or acetone.24 Pour in a sufficient amount, allow to work for 10 minutes. Both agents help to dissolve ear wax, the compound, or both. Repeat if needed to debond the cyanoacrylate from the ear canal.24,25 Irrigation Irrigation is the default for non-organic foreign bodies that are not amenable to other extraction techniques. Sometimes the object is encased in cerumen, and the only “instrument” that will fit behind the foreign body is the slowly growing trickle of water that builds enough pressure to expulse it. Do not use if there is any organic material involved: the object will swell, causing much more pain, difficulty in extraction, and possibly setting up conditions for infection. Position the child either prone or supine, gently restrain (as above). Let gravity work for you: don’t irrigate in decubitus position with the affected ear up. It may be more accessible to you, but you may never get the foreign body out. To use a butterfly needle: use a small gage (22 or 24 g) butterfly set up, cut off the needle, connect the tubing to a 30 mL syringe filled with warm or room-temperature water. Insert the free end of the tubing gently, and “secure” the tubing with your pinched fingers while irrigating (think of holding an ETT in place just after intubation and before taping/securing the tube). Gently and slowly increase the pressure you exert as you irrigate. To use an IV or angiocatheter: use a moderate size (18 or 20 g) IV, remove the needle and attach the plastic catheter to a 20 mL syringe, and irrigate as above. Acetone Acetone has been used successfully to remove chewing gum, Styrofoam, and superglue from the ear canal24,26,27 Use in cases where there is no suspicion of perforation of the tympanic membrane. Docusate Sodium (Colace®) Cerumen is composed of sebaceous ad ceruminous secretions and desquamated skin. Genetic, environmental, and anatomical factors combine to trap a foreign body in the external canal. Use of a ceruminolytic such as docusate sodium may help to loosen and liberate the foreign body.28 Caveat medicus: Adding docusate sodium will make the object more slippery – this may or may not be an issue given the nature of the foreign body. In the case where loosening the ear wax may aid extraction (and will not cause a slippery mess), consider filling the ear canal will docusate sodium (Colace), having the child lie with the affected side up, waiting 15 minutes, and proceeding. This is especially helpful when planning for irrigation. Magnets Rare earth magnets (a misnomer, as their components are actually abundant) such as neodymium can be useful in retrieving metallic foreign bodies (e.g. button batteries in the nose or ears).29,30 Magnetic “pick-up tools” – used by mechanics, engineers, and do-it-yourselfers – are inexpensive and readily available in various sizes, shapes, and styles such as a telescoping extender. Look for a small tip diameter (to fit in the ear canal as well as the nose) and a strong “hold” (at least a 3-lb hold). Alternatively, you may purchase a strong neodymium bar magnet (30- to 50-lb hold) to attach to an instrument such as an alligator forceps, pick-up forceps, or small hemostat (a pacemaker magnet may also work). The magnetic bar, placed in your palm at the base of the instrument, will conduct the charge (depending on the instrument) and allow you to retrieve many metallic objects.31 Although stainless steel is often said to be “non-magnetic”, it depends on the alloy used, and some may actually respond to the strong rare earth magnet. Most stainless steel has a minimum of 10.5% chromium, which gives the steel its 'stainless' properties (essentially corrosion resistance). A basic stainless steel has a “ferritic” structure and is magnetic. Higher-end stainless steel such as in kitchen cutlery have an “austenitic” structure, with more chromium added, and so less magnetic quality. (Ironically, the more “economical” instruments in the typical ED suture kit have less chromium, and so are more magnetic – use these with your neodymium bar magnet to conduct the magnetic charge and extract the metallic foreign body.) Bottom line: if it’s metal, it’s worth a try to use a magnet. Even if the metal is very weakly magnetic, the strong neodymium magnet may still be able to exert a pull on it and aid in extraction. Snare Technique A relatively new method, described by Fundakowski et al.32 consists of using a small length of 24-gauge (or similar) wire (available inexpensively online, and kept in your personal “toolkit”; see Appendix B below) to make a loop that is secured by a hemostat (the 24-gauge wire is easily cut into strips with standard trauma scissors). After treatment with oxymetolazone (0.05%) and lidocaine (1 or 2%) topically, the loop is passed behind the foreign body (in the case report, a button battery). Pull the loop toward you until you feel that it is sitting up against the button battery. Now, turn the hemostat 90° to improve your purchase on the foreign body. Pull gently out. This technique is especially useful when the foreign body has created marked edema, either creating a vacuum effect or making it difficult for other instruments to pass. Balloon Catheters (Katz extractor®, Fogarty embolectomy catheter) Small-caliber devices (5, 6, or 8 F) originally designed for use with intravascular or bladder catheterization may be used to extract foreign bodies from the ear or nose.7,33 A catheter designed specifically for foreign body use is the Katz extractor. Inspect the ear or nose for potential trauma and to anticipate bleeding after manipulation (especially the nose). Deflate the catheter and apply surgical lubricant or 2% lidocaine jelly. Insert the deflated catheter and gently pass the device past the foreign body. Inflate the balloon and slowly pull the balloon and foreign body out. Re-inspect after extraction. NB, from the manufacturer of the Katz extractor, InHealth: “the Katz Extractor oto-rhino foreign body remover is intended principally for extraction of impacted foreign bodies in the nasal passages. This device may also be used in the external ear canal, based upon clinical judgment.” Mother’s kiss The mother’s kiss was first described in 1965 by Vladimir Ctibor, a general practitioner from New Jersey.34 “The mother, or other trusted adult, places her mouth over the child’s open mouth, forming a firm seal as if about to perform mouth-to-mouth resuscitation. While occluding the unaffected nostril with a finger, the adult then blows until feeling resistance caused by closure of the child’s glottis, at which point the adult gives a sharp exhalation to deliver a short puff of air into the child’s mouth. This puff of air passes through the nasopharynx, out through the non-occluded nostril and, if successful, results in the expulsion of the foreign body. The procedure is fully explained to the adult before starting, and the child is told that the parent will give him or her a “big kiss” so that minimal distress is caused to the child. The procedure can be repeated a number of times if not initially successful.”34 Positive Pressure Ventilation with Bag Valve Mask This technique is an approximation of the above mother’s kiss technique – useful for unwilling parents or unsuccessful tries.10,25 The author prefers to position the child sitting up. A self-inflating bag-mask device is fitted with a very small mask: use an abnormally small mask (otherwise inappropriately small for usual resuscitative bag-mask ventilation) to fit over the mouth only. Choose an infant mask that will cover the child’s mouth only. Occlude the opposite nostril with your finger while you form a tight seal with the mask around the mouth. Deliver short, abrupt bursts of ventilation through the mouth – be sure to maintain good seals with the mask and with your finger to the child’s nostril – until the foreign body is expulsed through the affected nostril. Beamsley Blaster (Continuous Positive Pressure) Technique For the very uncooperative child with a nasal foreign body amenable to positive pressure ventilation who fails the mother’s kiss and bag-mask technique, a continuous positive pressure method may be used. Connect one end of suction tubing to the male adaptor (“Christmas tree”) of an air or oxygen source. Connect the other end of the suction tubing to a male-to-male adaptor (commonly used for chest tube connections or connecting / extending suction tubes). Insert the end of the device into the child’s unaffected nostril. The air flow will deliver positive pressure ventilation continuously. With this technique there is a theoretical risk of barotrauma to the lungs or tympanic membranes. However, there is only one case reported in the literature of periorbital subcutaneous emphysema. To minimize this risk, some authors recommend limiting to a maximum of four attempts using any positive pressure method.10 Nasal speculum Optimize your visualization with a nasal speculum. The nostrils, luckily, will accommodate a fair amount of distention without damage. Hold the speculum vertically to avoid pressure on and damage to the vessel-and-nerve-rich nasal septum. Hold the handle of the speculum in the palm of your hand comfortably and while placing your index finger on the patient’s ala. This will help to control the speculum and your angle of sight. Your other hand is then free to use a hook or other tool for extraction. Lighting is especially important when using the nasal speculum: a focused procedure light or head lamp is very helpful. The author keeps a common camping LED headlamp in his bag for easy access. Suction tips / catheters Various commercial and non-commercial suction devices are on the market for removal of foreign bodies. All connect to wall suction, and vary by style, caliber of suction, and tip end interface. A commonly available suction catheter is the Frazier suction tip (right), a single-use device used in the operating room. A modification to suction can be made with the Schuknecht foreign body remover (left; not to be confused with the suction catheter of the same name): a plastic cone-shaped tip placed on the end of the suction catheter to increase vacuum surface area and seal. Laryngoscope and Magill Forceps If a child aspirates and occludes his airway, return to BLS maneuvers (as above). If the child becomes obtunded, use direct laryngoscopy to visualize the foreign body and remove with the Magill forceps. Hold the laryngoscope in your left hand as per usual. Hold the Magill forceps in your right hand – palm side down – to grasp and remove the foreign body. Take-home Points Beware the “vacuum palate”: a flat (especially clear plastic) foreign body hiding on the palate Take seriously the complaint of foreign body without obvious evidence on initial inspection – believe that something is in there until proven otherwise Control the environment, address analgesia and anxiolysis, have a back-up plan Motto Like a difficult airway: plan through the steps MERCI – DANKE – Дякую – THANK YOU – GRACIAS – ありがとう— GRAZIE Appendix A: Prevention At the end of the visit, after some rapport has been established, counsel the caregivers about age-appropriate foods and “child-proofing” the home. This is a teachable moment – and only you can have this golden opportunity! Age-appropriate foods 0-6 months: breastmilk or formula 6-9 months: introduce solid puree-consistency foods 9-12 months: small minced solids that require no chewing (well cooked, soft, chopped foods) Although molars (required for chewing) erupt around 18 months, toddlers need to develop coordination, awareness to eat hard foods that require considerable chewing. Not until 4 years of age (anything that requires chewing to swallow): Hot dogs Nuts and seeds Chunks of meat or cheese Whole grapes Hard or sticky candy Popcorn Chunks of peanut butter Chunks of raw vegetables Chewing gum Child-proofing the home Refer parents to the helpful multi-lingual site from the American Academy of Pediatrics: http://www.healthychildren.org/English/safety-prevention/at-home/Pages/Childproofing-Your-Home.aspx An abbreviated list: use age-appropriate toys and “test” them out before giving them to your child to verify that there are no small, missing, or loose parts. Secure medications, lock up cabinets (especially with chemicals), do not store chemicals in food containers, secure the toilet bowl, and unplug appliances. Parents should understand that “watching” their child alone cannot prevent foreign body aspiration: a recent review found that in 84.2% of cases, incidents resulting in an airway foreign body occurred in the presence of an adult.35 Best overall tip: get down on all fours and inspect your living area from the child’s perspective. It is amazing what you will find when you are least expecting it. Appendix B: The Playbook's ENT Foreign Body Toolkit Although your institution should supply you with what you need to deal with routine problems, we all struggle with having just what we need when we need it. High-volume disposable items such as cyanoacrylate (Dermabond), curettes, supplies for irrigation, alligator forceps, and the like certainly should be supplied by the institution. However, some things come in very handy as our back-up tools. NB: we should be cognizant of the fact that tools that must be sterilized or autoclaved are not good candidates for our personal re-usable toolkits. These items can all be found inexpensively – shop around online, or in home improvement stores: Head lamp, LED camping style: $5-15 Neodymium magnet “pick-up tool”: $5-15 Neodymium bar magnet: $6-20 Wire, 24-gauge, spool of 25 yards (for snare technique): $6 Day hook: $15-20 References Chapin MM, Rochette LM, Annest JL, Haileyesus T, Conner KA, Smith GA. Nonfatal Choking on Food Among Children 14 Years or Younger in the United States, 2001–2009. Pediatrics. 2013;132(2):275-281. doi:10.1542/peds.2013-0260. Committee on Injury V. Policy Statement—Prevention of Choking Among Children. Pediatrics. 2010:peds.2009-2862. doi:10.1542/peds.2009-2862. Brown L, Denmark TK, Wittlake WA, Vargas EJ, Watson T, Crabb JW. Procedural sedation use in the ED: management of pediatric ear and nose foreign bodies. Am J Emerg Med. 2004;22(4):310-314. Heim SW, Maughan KL. Foreign bodies in the ear, nose, and throat. Am Fam Physician. 2007;76(8):1185-1189. DiMuzio J, Deschler DG. Emergency department management of foreign bodies of the external ear canal in children. Otol Neurotol Off Publ Am Otol Soc Am Neurotol Soc Eur Acad Otol Neurotol. 2002;23(4):473-475. Leffler S, Cheney P, Tandberg D. Chemical immobilization and killing of intra-aural roaches: an in vitro comparative study. Ann Emerg Med. 1993;22(12):1795-1798. Kiger JR, Brenkert TE, Losek JD. Nasal foreign body removal in children. Pediatr Emerg Care. 2008;24(11):785-792; quiz 790-792. doi:10.1097/PEC.0b013e31818c2cb9. Kadish HA, Corneli HM. Removal of nasal foreign bodies in the pediatric population. Am J Emerg Med. 1997;15(1):54-56. Tahir N, Ramsden WH, Stringer MD. Tracheobronchial anatomy and the distribution of inhaled foreign bodies in children. Eur J Pediatr. 2009;168(3):289-295. doi:10.1007/s00431-008-0751-9. Rempe B, Iskyan K, Aloi M. An Evidence-Based Review of Pediatric Retained Foreign Bodies. Pediatr Emerg Med Pract. 6(12). Digoy GP. Diagnosis and management of upper aerodigestive tract foreign bodies. Otolaryngol Clin North Am. 2008;41(3):485-496, vii - viii. doi:10.1016/j.otc.2008.01.013. Loren Yamamoto, Inaba A, DiMauro R. Radiologic Cases in Pediatric Emergency Medicine; University of Hawaii. Radiol Cases Emerg Med. http://www.hawaii.edu/medicine/pediatrics/pemxray/zindex.html. Accessed February 20, 2015. Painter K. Energizer makes button battery packages safer for kids. USA Today. ASGE Standards of Practice Committee, Ikenberry SO, Jue TL, et al. Management of ingested foreign bodies and food impactions. Gastrointest Endosc. 2011;73(6):1085-1091. doi:10.1016/j.gie.2010.11.010. Sharieff GQ, Brousseau TJ, Bradshaw JA, Shad JA. Acute esophageal coin ingestions: is immediate removal necessary? Pediatr Radiol. 2003;33(12):859-863. doi:10.1007/s00247-003-1032-4. Cohen S, Avital A, Godfrey S, Gross M, Kerem E, Springer C. Suspected Foreign Body Inhalation in Children: What Are the Indications for Bronchoscopy? J Pediatr. 2009;155(2):276-280. doi:10.1016/j.jpeds.2009.02.040. Haliloglu M, Ciftci AO, Oto A, et al. CT virtual bronchoscopy in the evaluation of children with suspected foreign body aspiration. Eur J Radiol. 2003;48(2):188-192. doi:10.1016/S0720-048X(02)00295-4. Jung SY, Pae SY, Chung SM, Kim HS. Three-dimensional CT with virtual bronchoscopy: a useful modality for bronchial foreign bodies in pediatric patients. Eur Arch Otorhinolaryngol. 2011;269(1):223-228. doi:10.1007/s00405-011-1567-1. Hussain SZ, Bousvaros A, Gilger M, et al. Management of ingested magnets in children. J Pediatr Gastroenterol Nutr. 2012;55(3):239-242. doi:10.1097/MPG.0b013e3182687be0. Brown JC, Otjen JP, Drugas GT. Too attractive: the growing problem of magnet ingestions in children. Pediatr Emerg Care. 2013;29(11):1170-1174. doi:10.1097/PEC.0b013e3182a9e7aa. Brown JC, Otjen JP, Drugas GT. Pediatric magnet ingestions: the dark side of the force. Am J Surg. 2014;207(5):754-759; discussion 759. doi:10.1016/j.amjsurg.2013.12.028. Menner AL. Pocket Guide to the Ear: A Concise Clinical Text on the Ear and Its Disorders. Thieme; 2011. Colina D, Dudek S, Lin M. Tricks of the Trade: ENT Dilemmas - How Do I Get That Out of There? ACEP News. http://www.acep.org/Clinical---Practice-Management/Tricks-of-the-Trade--ENT-Dilemmas---How-Do-I-Get-That-Out-of-There-/?__taxonomyid=118010. Published July 2009. Accessed February 5, 2015. Abadir WF, Nakhla V, Chong P. Removal of superglue from the external ear using acetone: case report and literature review. J Laryngol Otol. 1995;109(12):1219-1221. Kadish H. Ear and Nose Foreign Bodies “It is all about the tools.” Clin Pediatr (Phila). 2005;44(8):665-670. doi:10.1177/000992280504400803. Chisholm EJ, Barber-Craig H, Farrell R. Chewing gum removal from the ear using acetone. J Laryngol Otol. 2003;117(4):325. doi:10.1258/00222150360600995. White SJ, Broner S. The use of acetone to dissolve a Styrofoam impaction of the ear. Ann Emerg Med. 1994;23(3):580-582. Singer AJ, Sauris E, Viccellio AW. Ceruminolytic effects of docusate sodium: a randomized, controlled trial. Ann Emerg Med. 2000;36(3):228-232. doi:10.1067/mem.2000.109166. Bledsoe RD. Magnetically adherent nasal foreign bodies: a novel method of removal and case series. Am J Emerg Med. 2008;26(7):839.e1-e839.e2. doi:10.1016/j.ajem.2008.01.036. Dolderer JH, Kelly JL, Morrison WA, Penington AJ. FOREIGN-BODY RETRIEVAL USING A RARE EARTH MAGNET: Plast Reconstr Surg. 2004;113(6):1869-1870. doi:10.1097/01.PRS.0000119869.01081.1C. Yeh B, Roberson JR. Nasal magnetic foreign body: a sticky topic. J Emerg Med. 2012;43(2):319-321. doi:10.1016/j.jemermed.2010.02.013. Fundakowski CE, Moon S, Torres L. The snare technique: a novel atraumatic method for the removal of difficult nasal foreign bodies. J Emerg Med. 2013;44(1):104-106. doi:10.1016/j.jemermed.2012.07.070. Chan TC, Ufberg J, Harrigan RA, Vilke GM. Nasal foreign body removal. J Emerg Med. 2004;26(4):441-445. doi:10.1016/j.jemermed.2003.12.024. Cook S, Burton M, Glasziou P. Efficacy and safety of the “mother’s kiss” technique: a systematic review of case reports and case series. Can Med Assoc J. 2012;184(17):E904-E912. doi:10.1503/cmaj.111864. Gregori D, Morra B, Snidero S, et al. Foreign bodies in the upper airways: the experience of two Italian hospitals. J Prev Med Hyg. 2007;48(1):24-26. This post and podcast are dedicated to Linda Dykes, MBBS(Hons) for her can-do attitude and collaborative spirit. Thank you for sharing your knowledge, experience, and heart with the world.
It may look like water, but CSF is anything but. In this week's episode of BrainWaves, we discuss the contents of CSF and how to interpret them. BrainWaves podcasts and online content are intended for medical education only and should not be used to guide medical decision making in routine clinical practice. REFERENCES 1. Frederiks JA and Koehler PJ. The first lumbar puncture. J Hist Neurosci. 1997;6:147-53. 2. Seehusen DA, Reeves MM and Fomin DA. Cerebrospinal fluid analysis. Am Fam Physician. 2003;68:1103-8. 3. Shah KH and Edlow JA. Distinguishing traumatic lumbar puncture from true subarachnoid hemorrhage. J Emerg Med. 2002;23:67-74. 4. Deisenhammer F, Bartos A, Egg R, Gilhus NE, Giovannoni G, Rauer S, Sellebjerg F and Force ET. Guidelines on routine cerebrospinal fluid analysis. Report from an EFNS task force. European journal of neurology : the official journal of the European Federation of Neurological Societies. 2006;13:913-22. 5. Nagel MA, Cohrs RJ, Mahalingam R, Wellish MC, Forghani B, Schiller A, Safdieh JE, Kamenkovich E, Ostrow LW, Levy M, Greenberg B, Russman AN, Katzan I, Gardner CJ, Hausler M, Nau R, Saraya T, Wada H, Goto H, de Martino M, Ueno M, Brown WD, Terborg C and Gilden DH. The varicella zoster virus vasculopathies: clinical, CSF, imaging, and virologic features. Neurology. 2008;70:853-60. 6. Messacar K, Schreiner TL, Van Haren K, Yang M, Glaser CA, Tyler KL and Dominguez SR. Acute flaccid myelitis: A clinical review of US cases 2012-2015. Annals of neurology. 2016;80:326-38.
When you give only after you're asked, you've waited too long. – John Mason First, learn to bag Place a towel roll under the scapulae to align oral, pharyngeal, and tracheal axes: Karsli C. Can J Anesth. 2015. Use airway adjuncts such as the oropharyngeal airway or a nasal trumpet. Use the two-hand ventilation technique whenever possible: (See Adventures in RSI for more) Supraglottic Airways: for difficult bag-valve-mask ventilation or a difficult airway (details in audio) LMA Classic Pros: Best studied; sizes for all ages Cons: Cannot intubate through aperture LMA Supreme Pros: Better ergonomics with updated design; bite bloc; port for decompression Cons: Cannot pass appropriate-sized ETT through tube King Laryngeal Tube Pros: Little training needed; high success rate; single inflation port Cons: Flexion of tube can impede ventilation or cause leaks; only sized down to 12 kg (not for infants and most toddlers) Air-Q Pros: Easy to place; can intubate through aperture Cons: Not for neonates less than 4 kg iGel Pros: Molds more accurately to supraglottis; no need to inflate; good seal pressures Cons: Cannot intubate through (without fiberoscopy) Summary • If you can bag the patient, you're winning. • If you have difficulty bagging, or anticipate or encounter a difficult airway, then don't forget your friend the supraglottic airway (SGA). • Ego is the enemy of safety: SGAs are simple, fast, and reliable. • Just do it. References Ahn EJ et al. Comparative Efficacy of the Air-Q Intubating Laryngeal Airway during General Anesthesia in Pediatric Patients: A Systematic Review and Meta-Analysis. Biomed Res Int. 2016;2016:6406391. Black AE, Flynn PE, Smith HL, Thomas ML, Wilkinson KA; Association of Pediatric Anaesthetists of Great Britain and Ireland. Development of a guideline for the management of the unanticipated difficult airway in pediatric practice. Paediatr Anaesth. 2015 Apr;25(4):346-62. Byars DV et al. Comparison of direct laryngoscopy to Pediatric King LT-D in simulated airways. Pediatr Emerg Care. 2012 Aug;28(8):750-2. Carlson JN, Mayrose J, Wang HE. How much force is required to dislodge an alternate airway? Prehosp Emerg Care. 2010 Jan-Mar;14(1):31-5. Diggs LA, Yusuf JE, De Leo G. An update on out-of-hospital airway management practices in the United States. Resuscitation. 2014 Jul;85(7):885-92. Ehrlich PF et al. Endotracheal intubations in rural pediatric trauma patients. J Pediatr Surg. 2004 Sep;39(9):1376-80. Hernandez MR, Klock PA Jr, Ovassapian A. Evolution of the extraglottic airway: a review of its history, applications, and practical tips for success. Anesth Analg. 2012 Feb;114(2):349-68. Huang AS, Hajduk J, Jagannathan N. Advances in supraglottic airway devices for the management of difficult airways in children. Expert Rev Med Devices. 2016;13(2):157-69. Jagannathan N, Wong DT. Successful tracheal intubation through an intubating laryngeal airway in pediatric patients with airway hemorrhage. J Emerg Med. 2011 Oct;41(4):369-73. Jagannathan N et al. Elective use of supraglottic airway devices for primary airway management in children with difficult airways. Br J Anaesth. 2014 Apr;112(4):742-8. Jagannathan N, Ramsey MA, White MC, Sohn L. An update on newer pediatric supraglottic airways with recommendations for clinical use. Paediatr Anaesth. 2015 Apr;25(4):334-45. Karsli C. Managing the challenging pediatric airway: Continuing Professional Development. Can J Anaesth. 2015 Sep;62(9):1000-16. Luce V et al. Supraglottic Airway Devices vs Tracheal Intubation in Children: A Quantitative Meta-Analysis of Respiratory Complications. Paediatr Anaesth 24 (10), 1088-1098. Nicholson A et al. Supraglottic airway devices versus tracheal intubation for airway management during general anaesthesia in obese patients. Cochrane Database Syst Rev. 2013 Sep 9;(9):CD010105. Ostermayer DG, Gausche-Hill M. Supraglottic airways: the history and current state of prehospital airway adjuncts. Prehosp Emerg Care. 2014 Jan-Mar;18(1):106-15. Rosenberg MB, Phero JC, Becker DE. Essentials of airway management, oxygenation, and ventilation: part 2: advanced airway devices: supraglottic airways. Anesth Prog. 2014 Fall;61(3):113-8. Schmölzer GM, Agarwal M, Kamlin CO, Davis PG. Supraglottic airway devices during neonatal resuscitation: an historical perspective, systematic review and meta-analysis of available clinical trials. Resuscitation. 2013 Jun;84(6):722-30. Sinha R, Chandralekha, Ray BR. Evaluation of air-Q™ intubating laryngeal airway as a conduit for tracheal intubation in infants--a pilot study. Paediatr Anaesth. 2012 Feb;22(2):156-60. Timmermann A. Supraglottic airways in difficult airway management: successes, failures, use and misuse. Anaesthesia. 2011 Dec;66 Suppl 2:45-56. Timmermann A, Bergner UA, Russo SG. Laryngeal mask airway indications: new frontiers for second-generation supraglottic airways. Curr Opin Anaesthesiol. 2015 Dec;28(6):717-26. Supraglottic Airway on WikEM This post and podcast are dedicated to Tim Leeuwenburg, MBBS FRACGP FACRRM DRANZCOG DipANAES and Rich Levitan, MD, FACEP for keeping our minds and our patients' airways -- open. You make us better doctors. Thank you. Powered by #FOAMed — Tim Horeczko, MD, MSCR, FACEP, FAAP Pediatric; Emergency Medicine; Pediatric Emergency Medicine; Podcast; Pediatric Podcast; Emergency Medicine Podcast; Horeczko; Harbor-UCLA; Presentation Skills; #FOAMed #FOAMped #MedEd
This week we discuss an age-old debate: Calcium Channel Blockers or Beta Blockers for rate control in atrial fibrillation. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_64_0_Final_Cut.m4a Download Leave a Comment Tags: Atrial Fibrillation, Beta Blocker, Calcium Channel Blocker, Cardiology, Rate Control Show Notes CoreEM: Recent Onset Atrial Fibrillation ALiEM: Atrial Fibrillation Rate Control in the ED: Calcium Channel Blockers or Beta Blockers? ALiEM: Beta Blockers vs Calcium Channel Blockers for Atrial Fibrillation Rate Control: Thinking Beyond the ED Fromm C, et al. Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in the Emergency Department. J Emerg Med. 2015 Apr 22. PMID 25913166
This week we discuss an age-old debate: Calcium Channel Blockers or Beta Blockers for rate control in atrial fibrillation. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_64_0_Final_Cut.m4a Download Leave a Comment Tags: Atrial Fibrillation, Beta Blocker, Calcium Channel Blocker, Cardiology, Rate Control Show Notes CoreEM: Recent Onset Atrial Fibrillation ALiEM: Atrial Fibrillation Rate Control in the ED: Calcium Channel Blockers or Beta Blockers? ALiEM: Beta Blockers vs Calcium Channel Blockers for Atrial Fibrillation Rate Control: Thinking Beyond the ED Fromm C, et al. Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in the Emergency Department. J Emerg Med. 2015 Apr 22. PMID 25913166
This week we discuss an age-old debate: Calcium Channel Blockers or Beta Blockers for rate control in atrial fibrillation. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Podcast_Episode_64_0_Final_Cut.m4a Download Leave a Comment Tags: Atrial Fibrillation, Beta Blocker, Calcium Channel Blocker, Cardiology, Rate Control Show Notes CoreEM: Recent Onset Atrial Fibrillation ALiEM: Atrial Fibrillation Rate Control in the ED: Calcium Channel Blockers or Beta Blockers? ALiEM: Beta Blockers vs Calcium Channel Blockers for Atrial Fibrillation Rate Control: Thinking Beyond the ED Fromm C, et al. Diltiazem vs. Metoprolol in the Management of Atrial Fibrillation or Flutter with Rapid Ventricular Rate in the Emergency Department. J Emerg Med. 2015 Apr 22. PMID 25913166
In 2014 NICE updated their guidelines on Head Injury: assessment and early management. This included specific guidance for those patients on warfarin Guidance regarding the ongoing observation of these patients is not contained within the guideline but as with much of Emergency Medicine variation between departments and regions vary in the threshold to admit patients with a normal CT head due to concerns of these patients developing a delayed bleed. A recent systematic review and meta analysis on the topic has just been published and we thought it would be worth a look. Risk of Delayed Intracranial Hemorrhage in Anticoagulated Patients with Mild Traumatic Brain Injury: Systematic Review and Meta-Analysis. Chauny JM. J Emerg Med. Jul 26 2016 The paper gives an interesting take on the risk we are dealing with following a normal scan in presentation to the ED and whilst the papers contained may not be the strongest level of evidence the meta-analysis is probably the best we have to go on at present. Enjoy and we'd love to hear any of your thoughts!
This week we discuss the role of phenobarbital in the management of severe alcohol withdrawal. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_57_0_Final_Cut.m4a Download One Comment Tags: Alcohol Withdrawal, Phenobarbital, Toxicology Show Notes References Riggan MA et al. Regarding “Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo controlled study.” J Emerg Med 2016; 50 (6): 895-8. PMID: 27221017 Rosenson J et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo controlled study. J Emerg Med 2013; 44(3): 592-8. PMID: 2299978 Read More
This week we discuss the role of phenobarbital in the management of severe alcohol withdrawal. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_57_0_Final_Cut.m4a Download One Comment Tags: Alcohol Withdrawal, Phenobarbital, Toxicology Show Notes References Riggan MA et al. Regarding “Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo controlled study.” J Emerg Med 2016; 50 (6): 895-8. PMID: 27221017 Rosenson J et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo controlled study. J Emerg Med 2013; 44(3): 592-8. PMID: 2299978 Read More
This week we discuss the role of phenobarbital in the management of severe alcohol withdrawal. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_57_0_Final_Cut.m4a Download One Comment Tags: Alcohol Withdrawal, Phenobarbital, Toxicology Show Notes References Riggan MA et al. Regarding “Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo controlled study.” J Emerg Med 2016; 50 (6): 895-8. PMID: 27221017 Rosenson J et al. Phenobarbital for acute alcohol withdrawal: a prospective randomized double-blind placebo controlled study. J Emerg Med 2013; 44(3): 592-8. PMID: 2299978 Read More
Jeff Kline talks about PEs in older adults. What's different and what's the same for older vs younger patients? Find out here! See gempodcast.com/2016/06/02/pulmonary-emboli-in-older-adults/ for a full description, links, and to leave comments! Not a day goes by that an Emergency Physician doesn’t at least consider PE in a patient who presents with chest pain, dyspnea, or syncope. We have become familiar with using risk stratification tools like the Wells Score and the PERC criteria. But what do you do in older adults? All of them will automatically NOT be PERC negative because of their age. In this episode, with PE guru Jeff Kline, we discuss the presentation of PE in older adults, including the demographics, diagnosis, and how treatment may differ from younger adults in small, sub-massive, and massive PEs. Selected References: 1. Zondag W, Vingerhoets LM, Durian MF, et al. Hestia criteria can safely select patients with pulmonary embolism for outpatient treatment irrespective of right ventricular function. J Thromb Haemost. 2013;11(4):686-692. http://www.ncbi.nlm.nih.gov/pubmed/23336721 2. Beam DM, Kahler ZP, Kline JA. Immediate discharge and home treatment with rivaroxaban of low-risk venous thromboembolism diagnosed in two U.S. emergency departments: A one-year preplanned analysis. Acad Emerg Med. 2015;22(7):788-795. http://www.ncbi.nlm.nih.gov/pubmed/26113241 3. Kahler ZP, Kline JA. Standardizing the D-dimer assay: Proposing the D-dimer international managed ratio. Clin Chem. 2015;61(5):776-778. http://www.ncbi.nlm.nih.gov/pubmed/25816812 4. Kahler ZP, Beam DM, Kline JA. Cost of treating venous thromboembolism with heparin and warfarin versus home treatment with rivaroxaban. Acad Emerg Med. 2015;22(7):796-802. http://www.ncbi.nlm.nih.gov/pubmed/26111453 5. Zhang Y, Zhou Q, Zou Y, et al. Risk factors for pulmonary embolism in patients preliminarily diagnosed with community-acquired pneumonia: A prospective cohort study. J Thromb Thrombolysis. 2015. http://www.ncbi.nlm.nih.gov/pubmed/26370200 6. Sharp AL, Vinson DR, Alamshaw F, Handler J, Gould MK. An age-adjusted D-dimer threshold for emergency department patients with suspected pulmonary embolus: Accuracy and clinical implications. Ann Emerg Med. 2016;67(2):249-257. http://www.ncbi.nlm.nih.gov/pubmed/26320520 7. Kirschner JM, Kline JA. Is it time to raise the bar? age-adjusted D-dimer cutoff levels to exclude pulmonary embolism. Ann Emerg Med. 2014;64(1):86-87. http://www.ncbi.nlm.nih.gov/pubmed/24951413 8. Kline JA, Kabrhel C. Emergency evaluation for pulmonary embolism, part 2: Diagnostic approach. J Emerg Med. 2015;49(1):104-117. http://www.ncbi.nlm.nih.gov/pubmed/25800524 9. Kline JA, Courtney DM, Kabrhel C, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost. 2008;6(5):772-780. http://www.ncbi.nlm.nih.gov/pubmed/18318689 Image credit: http://anthrocolors.deviantart.com/art/Lungs-for-fresh-air-edited-298950224 This podcast uses sounds from freesound.org by Jobro and HerbertBoland
Ep #21 Ketamine Induced Rapid Sequence Intubation with Faizan H. Arshad, MD @emscritcare Happy #EMSWeek #EMSStrong #EMSNation SKEPTIC = Safety & Efficacy of Ketamine in Emergent Prehospital Tracheal Intubation – a Case Series Brand new paper from Sydney HEMS on Ketamine and Shock Index in Annals of EM! http://www.annemergmed.com/article/S0196-0644(16)30002-6/abstract Additional References: Carlson JN, Karns C, Mann NC, et al. Procedures performed by emergency medical services in the united states.Prehosp Emerg Care. 2015. Jacobs PE, Grabinsky A. Advances in prehospital airway management.International Journal of Critical Illness & Injury Science. 2014;4:57-64. Prekker ME, Kwok H, Shin J, Carlbom D, Grabinsky A, Rea TD. The process of prehospital airway management: Challenges and solutions during paramedic endotracheal intubation.Crit Care Med. 2014;42:1372-1378. Wang HE, Kupas DF, Greenwood MJ, et al. An algorithmic approach to prehospital airway management.Prehospital Emergency Care. 2005;9:145-155. Mace SE. Challenges and advances in intubation: Airway evaluation and controversies with intubation.Emerg Med Clin North Am. 2008;26:977-1000. Combes X, Jabre P, Jbeili C, et al. Prehospital standardization of medical airway management: Incidence and risk factors of difficult airway.Acad Emerg Med. 2006;13:828-834. Drummond GB. Comparison of sedation with midazolam and ketamine: effects on airway muscle activity. Br J Anaesth. 1996;76:663-667. Jackson APF, Dhadphale PR, callaghan ML, Alseri S. Haemodynamic studies during induction of anaesthesia for open-heart surgery using diazepam and ketamine. Br J Anaesth. 1978;50:375-378. Price B, Arthur AO, Brunko M, et al. Hemodynamic consequences of ketamine vs etomidate for endotracheal intubation in the air medical setting. Am J Emerg Med. 2013;31:1124-1132. Scherzer D, Leder M, Tobias JD. Pro-Con Debate: Etomidate or Ketamine for Rapid Sequence Intubation in Pediatric Patients. J Pediatr Pharmacol Ther. 2012;17:142-149. Bruder Eric A, Ball Ian M, Ridi S, Pickett W, Hohl C. Single induction dose of etomidate versus other induction agents for endotracheal intubation in critically ill patients.Cochrane Database of Systematic Reviews. 2015 Thompson Bastin ML, Baker SN, Weant KA. Effects of Etomidate on Adrenal Suppression: A Review of Intubated Septic Patients.Hospital Pharmacy. 2014;49:177-183. Arnold C. The promise and perils of ketamine research Ketamine began its life as an anaesthetic , but has enjoyed a recent renaissance as a potential. Lancet Neurol. 2013;12:940-941. Craven R. Ketamine. Anaesthesia. 2007;62:48-53. Perkins ZB, Gunning M, Crilly J, Lockey D, O’Brien B. The haemodynamic response to pre-hospital RSI in injured patients. Injury. 2013;44:618-623. Aroni F, Iacovidou N, Dontas I, Pourzitaki C, Xanthos T. Pharmacological Aspects and Potential New Clinical Applications of Ketamine: Reevaluation of an Old Drug. J Clin Pharmacol. 2009;49:957-964. Manthous CA. Avoiding circulatory complications during endotracheal intubation and initiation of positive pressure ventilation.J Emerg Med. 2010;38:622-631. Kohrs R, Durieux ME. Ketamine. Anesth Analg. 1998;87:1186-1193. Moy RJ, Clerc S Le. Trends in Anaesthesia and Critical Care Ketamine in prehospital analgesia and anaesthesia. Trends Anaesth Crit Care. 2011;1:243-245. Reich DL, Silvay G. Ketamine: an update on the first twenty-five years of clinical experience. Can J Anaesth. 1989;36(2):186-197. Porter K. Ketamine in prehospital care. Emerg Med J. 2004;21:351-354. Svenson JE, Abernathy MK. Ketamine for prehospital use: new look at an old drug. Am J Emerg Med. 2007;25:977-980. Johansson J, Sjöberg J, Nordgren M, Sandström E, Sjöberg F, Zetterström H. Prehospital analgesia using nasal administration of S-ketamine--a case series. Scand J Trauma Resusc Emerg Med. 2013;21:38. Filanovsky Y, Miller P, Kao J. Myth: Ketamine should not be used as an induction agent for intubation in patients with head injury. Can J Emerg Med. 2010;12:154-201. Himmelseher S, Durieux ME. Revising a Dogma: Ketamine for Patients with Neurological Injury? Anesth Analg. 2005;101:524-534. Kropf J a., Grossman MD, Genzlinger M a., Stoltzfus J, Stehly CD. 328 Ketamine versus Etomidate for Rapid Sequence Intubation in Traumatically Injured Patients: An Exploratory Study. Ann Emerg Med. 2012;60:S117. Angus DC, van dP. Severe sepsis and septic shock.N Engl J Med. 2013;369:840-851. Jabre P, Avenel A, Combes X, et al. Morbidity related to emergency endotracheal intubation-A substudy of the KETAmine SEDation trial. Resuscitation. 2011;82:517-522. Shafi S, Gentilello L. Pre-Hospital Endotracheal Intubation and Positive Pressure Ventilation Is Associated with Hypotension and Decreased Survival in Hypovolemic Trauma Patients: An Analysis of the National Trauma Data Bank. The Journal of Trauma: Injury, Infection, and Critical Care. 2005;59:1140–1147. Seymour CW, Band RA, Cooke CR, et al. Out-of-hospital characteristics and care of patients with severe sepsis: A cohort study.J Crit Care. 2010;25:553-562. Williams E, Arthur a., Price B, Banister NJ, Goodloe JM, Thomas SH. 175 Ketamine versus Etomidate for Use in Helicopter Emergency Medical Services Endotracheal Intubation. Ann Emerg Med. 2012;60:S63-S64 Bruns, B, Gentilello, L, Elliott, A, Shafi, S. Prehospital Hypotension Redefined. The Journal of Trauma: Injury, Infection, and Critical Care. 2008;65:1217–1221. Seymour, CW, Cooke, CR, Heckbert, SR, et al. Prehospital Systolic Blood Pressure Thresholds: A Community-based Outcomes Study. Acad Emerg Med Academic Emergency Medicine. 2013;20:597–604. Kristensen AKB, Holler JG, Mikkelsen S, Hallas J, Lassen A. Systolic blood pressure and short-term mortality in the emergency department and prehospital setting: a hospital-based cohort study.Critical Care. 2015;1:158. Heffner AC, Swords DS, Neale MN, Jones AE. Incidence and factors associated with cardiac arrest complicating emergency airway management. Resuscitation. 2013;84:1500-1504. Salt PJ, Baranes PK, Beswick FJ. Inhibition of neuronal and extraneuronal uptake of noradrenaline by ketamine in the isolated perfused rat heart. Br J Anaesth. 1979;51:835-838. Sprung J, Schuetz SM, Stewart RW, Moravec CS. Effects of Ketamine on the Contractility of Failing and Nonfailing Human Heart Muscles in Vitro. Surv Anesthesiol. 1999;43:230-231. Kunst G, Martin E, Graf BM, Hagl S, Vahl CF. Actions of Ketamine and Its Isomers on Contractility and Calcium Transients in Human Myocardium. Anesthesiology. 1999;90:1363-1371. Lundy PM, Lockwood PA, Thompson G, Frew R. Differential Effects of Ketamine Isomers on Neuronal and Extraneuronal Catecholamine Uptake Mechanisms. Anesthesiology. 1986;64:359-363. Selde W. Push dose epinephrine. A temporizing measure for drugs that have the side-effect of hypotension.JEMS. 2014;39:62-63. Sponsored by @PerfectCPR Apple Watch App with Audio and Haptic Feedback to Optimize Cardiac Arrest Training and Improve Quality of CPR Delivery PerfectCPR.com Query us on Twitter: www.twitter.com/EMS_Nation Like us on Facebook: www.facebook.com/prehospitalnation Wishing Everyone a safe tour! ~Faizan H. Arshad, MD @emscritcare www.emsnation.org
This week we review mandible dislocations and reduction approahces focusing on the new "syringe" technique. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_47_0_Final_Cut.m4a Download Leave a Comment Tags: Mandible Dislocation, Oral Surgery, Syringe Technique Show Notes Read More ALiEM: Tick of the Trade: Extra-oral reduction technique of anterior mandible dislocation Gorchynski J et al. The “syringe” technique: a hands-free approach for the reduction of acute nontraumatic temporomandibulardislocations in the emergency department. J Emerg Med. 2014; 47(6):676-81. PMID 25278137
This week we review mandible dislocations and reduction approahces focusing on the new "syringe" technique. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_47_0_Final_Cut.m4a Download Leave a Comment Tags: Mandible Dislocation, Oral Surgery, Syringe Technique Show Notes Read More ALiEM: Tick of the Trade: Extra-oral reduction technique of anterior mandible dislocation Gorchynski J et al. The “syringe” technique: a hands-free approach for the reduction of acute nontraumatic temporomandibulardislocations in the emergency department. J Emerg Med. 2014; 47(6):676-81. PMID 25278137
This week we review mandible dislocations and reduction approahces focusing on the new "syringe" technique. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_47_0_Final_Cut.m4a Download Leave a Comment Tags: Mandible Dislocation, Oral Surgery, Syringe Technique Show Notes Read More ALiEM: Tick of the Trade: Extra-oral reduction technique of anterior mandible dislocation Gorchynski J et al. The “syringe” technique: a hands-free approach for the reduction of acute nontraumatic temporomandibulardislocations in the emergency department. J Emerg Med. 2014; 47(6):676-81. PMID 25278137 Syri...
This week we discuss ovarian pathology focusing on ovarian torsion and tubo-ovarian abscess. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_37_0_Final_Cut.m4a Download Leave a Comment Tags: gynecology, Ovarian Torsion, TOA, tubo-ovarian abscess Show Notes Pediatric EM Morsels: Ovarian Torsion EM Lyceum: Ovarian Torsion Beigi, R.H. (2015). Epidemiology, clinical manifestations, and diagnosis of tuboovarian abscess. In S.J. Falk (Ed.), UpToDate. Waltham, MA, 2015. Beigi, R.H. (2015). Management and complications of tuboovarian abscess. In S.J. Falk (Ed.), UpToDate. Waltham, MA, 2015. Hart, D, Lipsky, A. Acute Pelvic Pain in Women. In: Marx JA, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014. p. 266-272. Lee D, Swaminathan A. Sensitivity of Ultrasound for the Diagnosis of Tubo-Ovarian Abscess: A Case Report and Literature Review. J Emerg Med. 2011 vol 40 (2): 170-5. PMID: 20466506 Tibbles, CD. Selected Gynecologic Disorders. In: Marx JA, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014. p. 1355-1362. Read More
This week we discuss ovarian pathology focusing on ovarian torsion and tubo-ovarian abscess. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_37_0_Final_Cut.m4a Download Leave a Comment Tags: gynecology, Ovarian Torsion, TOA, tubo-ovarian abscess Show Notes Pediatric EM Morsels: Ovarian Torsion EM Lyceum: Ovarian Torsion Beigi, R.H. (2015). Epidemiology, clinical manifestations, and diagnosis of tuboovarian abscess. In S.J. Falk (Ed.), UpToDate. Waltham, MA, 2015. Beigi, R.H. (2015). Management and complications of tuboovarian abscess. In S.J. Falk (Ed.), UpToDate. Waltham, MA, 2015. Hart, D, Lipsky, A. Acute Pelvic Pain in Women. In: Marx JA, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014. p. 266-272. Lee D, Swaminathan A. Sensitivity of Ultrasound for the Diagnosis of Tubo-Ovarian Abscess: A Case Report and Literature Review. J Emerg Med. 2011 vol 40 (2): 170-5. PMID: 20466506 Tibbles, CD. Selected Gynecologic Disorders. In: Marx JA, ed. Rosen's Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014. p. 1355-1362. Read More
This week we discuss ovarian pathology focusing on ovarian torsion and tubo-ovarian abscess. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_37_0_Final_Cut.m4a Download Leave a Comment Tags: gynecology, Ovarian Torsion, TOA, tubo-ovarian abscess Show Notes Pediatric EM Morsels: Ovarian Torsion EM Lyceum: Ovarian Torsion Beigi, R.H. (2015). Epidemiology, clinical manifestations, and diagnosis of tuboovarian abscess. In S.J. Falk (Ed.), UpToDate. Waltham, MA, 2015. Beigi, R.H. (2015). Management and complications of tuboovarian abscess. In S.J. Falk (Ed.), UpToDate. Waltham, MA, 2015. Hart, D, Lipsky, A. Acute Pelvic Pain in Women. In: Marx JA, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014. p. 266-272. Lee D, Swaminathan A. Sensitivity of Ultrasound for the Diagnosis of Tubo-Ovarian Abscess: A Case Report and Literature Review. J Emerg Med. 2011 vol 40 (2): 170-5. PMID: 20466506 Tibbles, CD. Selected Gynecologic Disorders. In: Marx JA, ed. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier Saunders; 2014. p. 1355-1362. Read More
This week, we review the management of post-partum hemorrhage focusing on identifying the cause, resuscitation and directed medical therapy. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_33_0_Final_Cut.m4a Download Leave a Comment Tags: Post-partum hemorrhage, Pregnancy Show Notes Core EM: Shoulder Dystocia Del Portal DA et al. Emergency department management of shoulder dystocia. J Emerg Med. 2014 Mar;46(3):378-82. PMID: 24360351 Lew GH, Pulia MS: Emergency Childbirth, in Roberts JR, Hedges JR, Custalow CB, et al (eds): Clinical Procedures in Emergency Medicine, ed 6. Philadelphia, Saunders, 2013, Ch 56:p 1155-82.
This week, we review the management of post-partum hemorrhage focusing on identifying the cause, resuscitation and directed medical therapy. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_33_0_Final_Cut.m4a Download Leave a Comment Tags: Post-partum hemorrhage, Pregnancy Show Notes Core EM: Shoulder Dystocia Del Portal DA et al. Emergency department management of shoulder dystocia. J Emerg Med. 2014 Mar;46(3):378-82. PMID: 24360351 Lew GH, Pulia MS: Emergency Childbirth, in Roberts JR, Hedges JR, Custalow CB, et al (eds): Clinical Procedures in Emergency Medicine, ed 6. Philadelphia, Saunders, 2013, Ch 56:p 1155-82.
This week, we review the management of post-partum hemorrhage focusing on identifying the cause, resuscitation and directed medical therapy. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Episode_33_0_Final_Cut.m4a Download Leave a Comment Tags: Post-partum hemorrhage, Pregnancy Show Notes Core EM: Shoulder Dystocia Del Portal DA et al. Emergency department management of shoulder dystocia. J Emerg Med. 2014 Mar;46(3):378-82. PMID: 24360351 Lew GH, Pulia MS: Emergency Childbirth, in Roberts JR, Hedges JR, Custalow CB, et al (eds): Clinical Procedures in Emergency Medicine, ed 6. Philadelphia, Saunders, 2013, Ch 56:p 1155-82.
In the young child, vomiting is the great imitator: Gastrointestinal, Neurologic, Metabolic, Respiratory, Renal, Infectious, Endocrine, Toxin-related, even Behavioral. To help us organize, below is a review of can't-miss diagnoses by age. The Neonate: Malrotation with Volvulus In children with malrotation, 50% present within the first month of life, with the majority occurring in the first week after birth. 90% of children with malrotation with volvulus will present by one year of age. This is a pre-verbal child’s disease – which makes it even more of a challenge to recognize quickly. The sequence of events usually is fussiness, irritability, and forceful vomiting. The vomit quickly turns bilious. Green vomit is a surgical emergency. Babies may also present unwell, with bloating and abdominal tenderness to palpation. Be aware that later stages of malrotation may present as shock – they present in hypovolemic shock due to third-spacing from necrotic bowel and/or septic shock from translocation or perforation. In the undifferentiated sick neonate, always consider a surgical emergency such as malrotation with volvulus. In the stable patient, get an upper GI contrast study. Rapid-fire word association for other vomiting emergencies in a neonate: Fever, irritability and vomiting? Think meningitis, UTI, or sepsis. Premature, unwell, and vomiting? Think necrotizing enterocolitis. Remember, 10% of cases of NEC can be full-term. Look for pneumatosis intestinalis. Systemically ill, afebrile, and vomiting for no other reason? Think inborn error of metabolism. Screen with a glucose, ammonia, lactate, and urine ketones. Others include congenital intestinal atresia or webs, meconium ileus, or severe GERD The Infant: Non-Accidental Trauma All that vomits is not necessarily from the gut. Abusive head injury is the most common cause of death from child abuse. Infants especially present with non-specific complaints like fussiness or vomiting. Up to 30% of infants with abusive head injury may be misdiagnosed on initial presentation. Louwers et al. in Child Abuse and Neglect developed and validated a six-question screening tool for use the in ED. The power of this tool was that it was validated for any chief complaint – it is not an injury evaluation checklist – it is a screen for potential abuse in the undifferentiated child: Is the history consistent? Was seeking medical help unnecessarily delayed? Does the onset of injury fit with the developmental level of the child? Is the behavior of the child and his interaction with his care-givers appropriate? Do the findings of the head-to-toe examination match the history? Are there any other red flags or signals that make you doubt the safety of the child or other family members? On multivariable analysis, if at least one of the questions was positive, there was an OR of 189 for abuse (CI 97 – 300). In other words, if any of those six questions are problematic, get your child protective team involved. Other important diagnoses in the infant: intussusception and pyloric stenosis (rapid review in audio). The Toddler: Diabetic Ketoacidosis (DKA) The important diagnosis not to miss in the vomiting toddler or early school age child is the initial presentation of diabetic ketoacidosis. Children under 5 (especially those under 2) and those from lower socioeconomic groups have a higher risk of DKA as their initial presentation of diabetes. This is true for any child that isn’t quite acting right – check a finger stick blood sugar as a screen. The International Society for Pediatric and Adolescent Diabetes (ISPAD) criteria for DKA: Hyperglycemia, with a blood glucose of >200 mg/dL (11 mmol/L) AND Evidence of metabolic acidosis, with a venous pH of less than 7.3 or a bicarbonate level of < 15 mEq/L AND Ketosis, found either in the urine or if directly checked in the blood. If you have access to checking a serum beta-hydroxybutryrate – the unsung ketone – it can help in diagnosis in unclear cases. Cerebral Edema Criteria: Minor criteria: headache, vomiting, irritability or lethargy; hypertension in the face of hypovolemia. Major criteria: change in mental status, including agitation or delirium; incontinence (especially if inappropriate for the child’s age); sluggish pupils and cranial nerve palsies; relative bradycardia (Cushing’s triad). Cerebral Edema Action Items: Immediately give mannitol, 1 g/kg over 15-20 minutes. May repeat it in 2 hours if needed. Hypertonic saline (3% NaCl) is second-line therapy. Put the head of the bed up 30 degrees. Alert your colleagues and counsel your parents. Make sure everyone knows what to watch out for. As you can see, vomiting in the young child can be really anything! Keep your differential broad, and think by age and by system. Differential Diagnosis of Vomiting in Children The general approach to the child with chiefly vomiting starts with the decision: sick or not sick. If ill appearing, establish rapid IV access, or if needed IO. Rapid blood sugar and if available a point of care pH and electrolytes. Be the detective in your history and doggedly go after any red flags as you go methodically by organ system. Do a careful physical exam. The general assessment is always helpful – is the child irritable, listless, agitated? What is his work of breathing? Effortless tachypnea may be a sign of acidosis or sepsis. Is the abdomen soft or is it tender or distended. Always look in the diaper area – is there a hernia, is there a high-riding, tender, discolored scrotum without cremasteric reflex? Ovarian torsion has been reported in infants as young as 7 months. Any skin signs? Look for petechiae, urticaria, purpura. In other words, use your best judgement, have the dangerous differentials in the back of your mind, and pull the trigger when red flags mount up. Otherwise, a good history and a good exam will get you where you need to be. Take home points for the young child with vomiting: Neonates are allowed to regurgitate (effortless reflux of stomach contents -- the happy spitter-upper). They are not allowed to vomit (forceful, unpleasant contraction of abdominal muscles). Consider surgical causes of forceful vomiting, especially if the child does not look anything other than well. Bilious is bad – green vomit is always a surgical emergency – do not pass go – get the surgeons involved early Not all vomiting is GI related – if it is not obviously benign, think methodically by organ system and adjust your targeted history and physical to pick up any leads. Match the tempo of your treatment to the tempo of the disease. References Applegate KE, Anderson JM, Klatte EC. Intestinal malrotation in children: a problem-solving approach to the upper gastrointestinal series. Radiographics. 2006; 26(5):1485-500. Glaser NS, Wootton-Gorges SL, Buonocore MH et al. Frequency of sub-clinical cerebral edema in children with diabetic ketoacidosis. Pediatr Diabetes. 2006 Apr;7(2):75-80. Louwers ECFM, Korfage IJ, Affourtit MJ et al. Accuracy of a screening instrument to identify potential child abuse in emergency departments. Child Abuse & Neglect. 2014; (38): 1275–1281. Lee HC, Pickard SS, Sridhar S et al. Intestinal Malrotation and Catastrophic Volvulus in Infancy. J Emerg Med. 2012; 43(1): e49–e51. Marcin JP, Glaser N, Barnett P et al. Factors associated with adverse outcomes in children with diabetic ketoacidosis-related cerebral edema. J Pediatr. 2002; 141(6):793-7. Parashette KR, Croffie J. Intestinal Malrotation in Children: A Problem-solving Approach to the Upper Gastrointestinal. Pediatrics in Review. 2013; (34)7: 307-321. Wolfsdorf JI, Allgrove J, Craig ME et al. ISPAD Clinical Practice Consensus Guidelines 2014. Diabetic ketoacidosis and hyperglycemic hyperosmolar state. Pediatr Diabetes. 2014 Sep;15 Suppl 20:154-79. This post and podcast are dedicated to Damian Roland, BMedSci (Hons), MB BS, MRCPCH, for his fervor in the care of children and his dedication to quality medical education. Nausea and Vomiting | Non-Accidental Trauma | DKA Powered by #FOAMed -- Tim Horeczko, MD, MSCR, FACEP, FAAP
Victims of electrical injuries present either in extremis or as the seeming well patient with insidious, developing disease. A targeted history usually gets you the information you need. Four main things to find out: 1. Household or Industrial electricity? Household electricity uses alternating current, or AC. Voltages across the world range anywhere from 100 to 240 V. Here in North America, most outlets and appliances use 120 volts, which is the measure of electrical tension, or the potential difference in electrical charge. Cut-off between low voltage and high voltage is 1000 V. Industrial energy may be AC or direct current, DC. DC current propels the victim -- think of this as a blast injury. The same voltage in AC is three times as damaging as that voltage at DC, because AC causes muscle tetany, and prolonged contact time. 2. What was the likely pathway that current took? Did the current pass through the thorax? -- Think dysrhythmias. Through the head or neck? -- Think damage to the CNS and risk for later central respiratory arrest; acoustic nerve damage; cataract formation. Did the current pass along an extremity? -- Think compartment syndrome and rhabdomyolysis. 3. What was the contact time? The electrical charge meets resistance and converts to thermal energy, which causes tissue necrosis, increasing with the contact time. Was your patient extricated? Was there tetany? Was he found in a pool of water or liquid? Longer contact time correlates with extensive injuries that may only be apparent hours later. 4. Are there any associated injuries? Think of electrical injury as a trauma – major trauma rarely occurs in isolation. Was the patient flung after contact? Did he have a syncopal episode? -- Think precipitated dysrhythmia and fall. Was there any chest pain? -- Consider stress-induced ischemia. Pearl: Patients may be confused initially or unable to localize symptoms because of CNS disruption. Get collateral information, re-interview, and re-examine as needed. Case 1: Toddler with an oral commissure burn An electrical burn to the angle of the mouth cauterizes superficial bleeding vessels, and hours later the wound becomes covered with a white layer of fibrin, surrounded by erythema. Edema and thrombosis will continue, and at 24 hours there is typically a significant margin of tissue necrosis. Most patients do well, and the burn heals by secondary intention. The eschar will slough off in 1 to 2 weeks. The labial artery is just deep to the burn, and as the eschar sloughs off, it can be exposed. It’s a high-flow artery to the face, and if disrupted, the child may have significant bleeding and possibly hemorrhagic shock. These children need close wound care follow-up, and potentially outpatient coordination with Head and Neck Surgery and/or Plastic Surgery consultants. Precautionary advice: take the moment to talk to parents about the risk, and show them how to apply pressure to the wound, pinching the inner and outer cheek together with the thumb and index finger until the child arrives to the hospital. Case 2: School-age child with knife versus electrical outlet A a “kissing burn” occurs when the electrical charge creates an arc and jumps to a more proximal portion of the extremity. The kissing burn typically occurs at flexor creases such as the wrist or the antecubital fossa. There is often extensive underlying tissue damage even under the skin where it doesn’t appear to be involved. Compartment syndrome and subsequent rhabdomyolysis and renal failure are the highest-risk complications. Case 3: Adolescent after a taser exposure Nitrogen capsules propel two barbs into the dermis, which deliver short bursts of energy; most patients have no harm from the electricity delivered. How to remove a dart: The darts are typically 9 mm long, but the small barb is typically not buried very deep in the skin. Hold the skin taught, use a hemostat to grasp the end as close to the skin as possible, align the dart perpendicularly to the skin, and pull quickly and firmly. If the patient can’t tolerate this or the barb appears particularly embedded, inject with local lidocaine and make a small superficial incision with an 11-blade scalpel just large enough to allow passage. Ultrasound can be used to troubleshoot when needed. Taser dispo: People who have been tased do remarkably well and complications are rare. In a review of tasers used by law enforcement, Vilke et al. found that there was no need for routine laboratory testing or observation, as there was ‘no evidence of dangerous laboratory abnormalities, physiologic changes, or immediate or delayed cardiac ischemia or dysrhythmias after exposure to electrical discharges of up to 15 s.” Subsequent studies with minors less than 16 years of age found similar results. Special note on the patient with agitated delirium or stimulant intoxication: treat these patients carefully, as the organic problem that got them tased in the first place still needs to be addressed, and substances such as PCP, cocaine, and methamphetamines are all cardiac irritants and may predispose them to dysrythmias. Case 4: Adolescent in full arrest after lightening strike Patients who are struck by direct current like lightening should be treated aggressively, because the reason for their cardiac arrest is often reversible if treated quickly. Either the current sent the victim into a dysrhythmia, or it caused a temporary paralysis of the thoracic muscles, resulting in a primary respiratory arrest. For victims of a lightning strike, classically we use reverse triage – normally, those in full arrest are triaged as black, deceases. In high-voltage and lightening injuries, we tend to those in full arrest first, because you might quickly reverse them, and can move on to the next patient triaged red, or immediate. High-voltage injuries are a multi-trauma – other sequelae include pulmonary edema, paralysis, ileus, and cataracts, in addition to the more immediate cardiac, musculoskeletal, neurologic, and renal considerations. Regardless of the exposure, obtain an ECG and look for bundle branch block, heart block, and dysrhythmias, since those will change disposition. In those who are injured, consider a basic metabolic panel, looking for potassium, calcium, and creatinine. A creatine phosphokinase or total CK will screen for rhabdomyolysis. Troponin is not predictive of the extent of direct myocardial damage, but get it if you think there might be a stress-induced, or type II MI. Radiography as needed depending on the presenting associated trauma. Take Home Points 1. Injury from electrical burns can be subtle. Think of patients as having occult multi-trauma. Be thorough in history and examination. Plan to re-examine either during observation in the ED, or in close outpatient follow-up. 2. Discharge patients with low-voltage injury, no symptoms, and a normal ECG. Counsel outpatients and provide close follow-up as appropriate. 3. Admit patients with low-voltage injury with signs or symptoms such as loss of consciousness, ECG changes, or evidence of end-organ damage on laboratory screening. Admit all patients with high-voltage injury, even if asymptomatic and a normal laboratory screen. 4. Transfer patients with high-voltage injury or significant burns to a regional burn center or trauma center. References Celik A, Ergün O, Ozok G. Pediatric electrical injuries: a review of 38 consecutive patients. J Pediatr Surg. 2004;39(8):1233-1237. Ericsson KA. Deliberate Practice and Acquisition of Expert Performance: A General Overview. Acad Emerg Med. 2008; 15:988-994. Fish RM. Electric injury, part I: treatment priorities, subtle diagnostic factors, and burns. J Emerg Med. 1999;17(6):977-983. doi:10.1016/S0736-4679(99)00127-4. Fish RM. Electric injury, part II: Specific injuries. J Emerg Med. 2000;18(1):27-34. doi:10.1016/S0736-4679(99)00158-4. Fish RM. Electric injury, part III: cardiac monitoring indications, the pregnant patient, and lightning. J Emerg Med. 2000;18(2):181-187. doi:10.1016/S0736-4679(99)00190-0. Horeczko T. “Electrical Injuries: Shocking or Subtle?” In Avoiding Common Errors in the Emergency Department, 2nd Edition. Mattu M, Swadron SP (eds). Lippincott, Williams & Wilkins. Phiadelphia. 2016. (In Press). Rai J, Jeschke MG, Barrow RE, Herndon DN. Electrical Injuries: A 30-Year Review. J Trauma Acute Care Surg. 1999;46(5):933-936. Vilke GM, Bozeman WP, Chan TC. Emergency department evaluation after conducted energy weapon use: review of the literature for the clinician. J Emerg Med. 2011; 40(5):598-604. This post and podcast are dedicated to Joelle Donofrio, MD, FAAP for her tireless care of children, in the ED and in the field. A special thank you and dedication to Cliff Reid, BM, FRCP(Glasg), FRCSEd(A&E), FRCEM, FACEM, FFICM, FCCP, EDIC, DCH, DipIMC, RCSEd, DipRTM, RCSEd, CCPU, CFEU for his transformative intelligence and educational verve.
This week we discuss some of the dangers of blood transfusions and pearls from our procedure workshops. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_Podcast_12_Final.m4a Download Leave a Comment Tags: Blood Transfusions, Cricothyroidotomy, Lateral Canthotomy, Tube Thoracostomy Show Notes Cricothyrotomy Resources EMCrit: EMCrit Wee – Mind Blowing Cricothyrotomy Video ACEP Now: Tips and Tricks for Performing Cricothyrotomy Tube Thoracostomy University of Maryland EM: Tube Thoracostomy Lateral Canthotomy Resources Rowh AD et al. Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome. J Emerg Med 2015. 48(3):325-330. PMID: 25524455 Larry Mellick: Emergency Lateral Canthotomy and Cantholysis
This week we discuss some of the dangers of blood transfusions and pearls from our procedure workshops. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_Podcast_12_Final.m4a Download Leave a Comment Tags: Blood Transfusions, Cricothyroidotomy, Lateral Canthotomy, Tube Thoracostomy Show Notes Cricothyrotomy Resources EMCrit: EMCrit Wee – Mind Blowing Cricothyrotomy Video ACEP Now: Tips and Tricks for Performing Cricothyrotomy Tube Thoracostomy University of Maryland EM: Tube Thoracostomy Lateral Canthotomy Resources Rowh AD et al. Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome. J Emerg Med 2015. 48(3):325-330. PMID: 25524455 Larry Mellick: Emergency Lateral Canthotomy and Cantholysis
This week we discuss some of the dangers of blood transfusions and pearls from our procedure workshops. https://media.blubrry.com/coreem/content.blubrry.com/coreem/Core_EM_Podcast_12_Final.m4a Download Leave a Comment Tags: Blood Transfusions, Cricothyroidotomy, Lateral Canthotomy, Tube Thoracostomy Show Notes Cricothyrotomy Resources EMCrit: EMCrit Wee – Mind Blowing Cricothyrotomy Video ACEP Now: Tips and Tricks for Performing Cricothyrotomy Tube Thoracostomy University of Maryland EM: Tube Thoracostomy Lateral Canthotomy Resources Rowh AD et al. Lateral canthotomy and cantholysis: emergency management of orbital compartment syndrome. J Emerg Med 2015. 48(3):325-330. PMID: 25524455 Larry Mellick: Emergency Lateral Canthotomy and Cantholysis
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