The Written Summary of the EM:RAP Monthly Audio Program

Transcription

The Written Summary of the EM:RAP Monthly Audio Program
March 2015: Volume 15, Issue 3
Editor-in-Chief: Mel Herbert, MD
Executive Editor: Paul Jhun, MD
Associate Editor: Marlowe Majoewsky, MD
www.emrap.org
Chronic Shoulder Dislocations
Mel Herbert MD interviews James Webley MD
A patient presents for a chronic shoulder dislocation. You try
to reduce it but are unsuccessful, so you decide to try again.
Is this a good idea?
In 1941, a French orthopedist named Calvet described the reduction of 91 chronic anterior shoulder dislocations, and 68 of
them had arterial ruptures. Half of those patients died. Later
textbooks said that reduction of chronic shoulder dislocations
should only be attempted in the operating room by an orthopedist, with a vascular surgeon on call.
Calvet, E et al. [Dislocations of the shoulder and vascular lesions.] (in French). J Chir (Paris) 1941; 58: 337-346.
In 2012, Verhaegen reported two cases of axillary artery rupture
in patients with reduction of a chronic shoulder dislocation. One
of the patients had only been dislocated for about 12 weeks.
Verhaegen F, et al. Chronic anterior shoulder dislocation: aspects of current management and potential complications. Acta
Orthop Belg. 2012 Jun;78(3):291-5. PMID: 22822566.
We all need to know about this. We see a lot of patients with
shoulder dislocations of unknown duration and frequently will try
to reduce them and see what happens. Is this a bad idea? Yes.
Chronic shoulder dislocation can result in adhesions between the displaced humerus and the artery. When you attempt to reduce it, it puts traction on the artery and can to lead
to rupture. This is more common in older patients.
What is considered chronic? About 3-4 weeks.
Sahajpal DT, et al. Chronic glenohumeral dislocation. J Am Acad
Orthop Surg. 2008 Jul;16(7):385-98. PMID: 18611996. A
review of the literature showed that of 50 chronic dislocations
treated by closed reduction, only 27 patients had good results;
these were reduced within 4 weeks of dislocation.
If patients have a chronic dislocation, there is no reason to
relocate it in the Emergency Department. Call your orthopedic
surgeon.
Paper Chase 1:
The Power of Suggestion
Sanjay Arora MD and Michael Menchine MD
Oktay C, et al. Contribution of verbal suggestion to the therapeutic efficacy of an analgesic agent for acute primary headache.
Cephalalgia. 2014 Oct 10. PMID: 25304763.
This is a study, conducted in Emergency Department (ED)
patients with primary headache, evaluating the power of
suggestion in enhancing analgesia. The authors conclude it
doesn’t work, but it merits a little more credit, and there doesn’t
seem to be any harm in it.
There are many studies on headache in the literature. There is
a lot of controversy regarding the best way to treat a headache.
There are other factors that can potentially contribute to the efficacy of a medication, such as patient-specific factors: “I need
Dilaudid!”
In this study, the authors examined the power of suggestion
as it impacts non-life-threatening headaches in the ED. They
conducted a prospective study of adult patients presenting to
the Emergency Department with primary headache. Patients
were all given intramuscular diclofenac, which is an NSAID. Patients were divided into three different groups: Group 1 received
the shot and were informed that they were receiving an intramuscular pain injection, without any associated positive or negative
suggestions; Group 2 was informed that they were receiving a
very powerful pain medication and relief of their headache was
expected within 45 minutes; and Group 3 was informed that
they would be given a second, more potent medication when
their headache did not improve within 45 minutes.
This was not a randomized controlled trial; patients were enrolled consecutively in 7 week blocks. There were many exclusions. Many of these exclusions were reasonable: the doctor
suspected a diagnosis different than primary headache, allergies
to NSAIDs, contraindications to NSAIDs, etc. However, many patients (40) were excluded due to an unwillingness to participate,
and 38 patients were excluded after their data was lost. During
the period of enrollment, they saw nearly 1,000 patients with
headache and excluded all but 153 from the study. The groups
were not evenly balanced. Group 2, who received the pain medication with associated positive suggestion, tended to be younger
EM:RAP Written Summary March 2015: Volume 15, Issue 3
1
The Written Summary of the
by about 7 years on average, and were nearly 75% female (compared to Group 1 which was about 50%). Patients were assessed
using a visual analog score at onset, at the time of medication
administration, and at 45 minutes post-administration.
All groups rated their headaches according to a visual analog
scale (VAS). At onset, all groups were similar, with a VAS score
of approximately 70. At 45 minutes, Group 1 had a VAS of 26.5,
Group 2 had a VAS of 17, and Group 3 had a VAS of 22. This did
not reach statistical significance. They also assessed the need
for additional pain medication. This was similar in Group 1 and
3, with about 33% requiring additional pain medication at 45
minutes. In group 2, only 24% of patients required additional
pain medication.
There were many limitations to this study, including the exclusion of about 85% of potential patients and uneven demographics among the group. Although not statistically significant,
the study does seem to show that the power of positive suggestion can help and certainly doesn’t hurt. The study should have
included patient satisfaction. Demonstrating care and managing
expectations is generally viewed positively by patients.
Pediatric Pearls:
Isolated Scalp Hematoma in Kids –
Should You CT?
Ilene Claudius MD Sol Behar MD and Peter Dayan MD
The PECARN minor head injury criteria from 2009 included
the presence of an isolated scalp hematoma as increased
risk of brain injury in children under the age of 2 years. It
is difficult to think that the smiling, happy, playful baby with no
symptoms other than an isolated scalp hematoma has an intracranial injury and may need a CT scan.
The PECARN investigators have revisited their data and
looked at the issue of isolated scalp hematomas.
Dayan PS, et al. Risk of traumatic brain injuries in children
younger than 24 months with isolated scalp hematomas. Ann
Emerg Med. 2014 Aug;64(2):153-62. PMID: 24635991.
The original PECARN study was a prospective cohort study
conducted at 25 centers in the United States. The primary aim
was to derive and validate clinical prediction rules. These were
published in Lancet in 2009. The study was designed with the
intention of using the data for secondary analysis. They were
interested in determining the prevalence of traumatic brain
injuries in children with different symptoms.
2
Monthly Audio Program
In addition to the prevalence of traumatic brain injuries with
isolated scalp hematomas, they looked at what factors increased or decreased the risk of more serious injury.
This sub-analysis only includes children younger than 2
years old. The outcome was clinically significant brain injury
(death, neurosurgery for traumatic brain injury, intubation >24
hours for traumatic brain injury, or positive CT scan in association with hospitalization >2 nights for traumatic brain injury).
They also looked at the outcome of traumatic brain injury on CT.
Not all of the children in the study with isolated scalp hematomas received a CT scan, so follow-up for outcomes was
important.
Fewer than 20% of children in this sub-analysis received CT
scans. Most physicians felt comfortable not obtaining a CT scan,
and this was more likely in children over the age of 6 months.
None of the 2,998 patients with isolated scalp hematomas
had neurosurgery. The risk of clinically important traumatic
brain injury overall was less than 1 in 200.
CT scans were obtained at the discretion of the treating physician. Almost 9% of the patients who received CT scan demonstrated traumatic brain injuries on CT. Risk factors were:
younger age (especially <3 months), non-frontal scalp hematomas, increased scalp hematoma size, and more severe
injury mechanism. A large hematoma was >3cm.
Some of the injuries identified on CT are not consequential.
How can you discuss risks and benefits with family members?
“We think there is low risk of having any abnormality that is going
to require intervention or is concerning to you or your child.” Most
families respond well to this and feel comfortable with a period of
observation.
PECARN low risk criteria: no loss of consciousness or loss of
consciousness <5 seconds, acting normally per parent or guardian, normal GCS score, no palpable skull fracture, no severe
mechanism of injury, and no signs of altered consciousness,
such as sleepiness or agitation. A non-frontal scalp hematoma
was the 6th criteria.
Clinicians often assess children younger than 24 months from
the perspective of either having no signs/symptoms other than
scalp hematomas or having a non-frontal hematoma and no
other signs/symptoms according to PECARN criteria. The study
described two definitions to reflect these approaches.
EM:RAP Written Summary | www.emrap.org
Extensive definition: No signs or symptoms other than frontal, parietal, temporal or occipital scalp hematoma
Patient with all of the following:
PECARN rule-based definition: No
signs or symptoms other than parietal,
temporal, or occipital scalp hematoma
defined by the PECARN prediction rule
variable for children younger than 24 mo
Patient with all of the following:
No history of LOC
No LOC or LOC <5s
Acting normally per parent or guardian
Acting normally per parent and guardian
Pediatric GCS score of 15
Pediatric GCS score of 15
No signs of altered consciousness
(sleepiness, agitation)
No signs of altered consciousness
No palpable skull fracture
No palpable skull fracture
No severe mechanism of injury
No signs of basilar skull fracture
No neurologic deficits
No vomiting after the head trauma
No seizure after the head trauma
These were fairly comparable.
Approximately 66% of children less than 3 months received a
CT scan compared to approximately 50% of children between
3-6 months. The perception that younger infants are at increased
risk of traumatic brain injury seems to be supported by the study.
There is also concern for non-accidental trauma in this population. This is unfortunate because these are the children who are
most at risk from radiation exposure. Dayan does not scan all
children with isolated hematomas under the age of 6 months, if
it is a very benign story and seems low risk for traumatic brain
injury. However, he does observe them for an extended period of
time in the Emergency Department.
We are concerned about detecting skull fractures because
there is a higher association with intracranial injury. Recent
studies have evaluated other modalities, such as ultrasound, for
detecting skull fracture. The preliminary data from a few small
studies shows fairly good sensitivity and specificity for the detection of skull fractures. There may be a role for ultrasound in
clinical prediction but the data is not there yet. Dayan will sometimes use skull x-rays in young infants, if it sounds like a minor
mechanism and the child has a very small hematoma. However,
he has a radiologist available who is skilled at reading the films.
The risk of intracranial injury without skull fracture is less than
1%. He will still observe the child even if skull films are negative.
What is the prevalence of clinically important traumatic brain
injury in children with isolated scalp hematoma and no other
symptoms? About 0.4% had a clinically important brain injury,
according to the PECARN definition. When they looked at kids
who had an isolated scalp hematoma but met all of the other
low-risk criteria, about 0.5% had clinically important injuries.
About 9.5% of patients with a mild mechanism of injury, who
received CT scan, had some type of injury identified on CT.
Use observation in the ED.
Paper Chase 2:
I Think You are Having a Heart Attack!
Body R, et al. Can emergency medicine physicians rule in or rule
out acute myocardial infarction with clinical judgment? Emerg
Med J. 2014 Nov:31(11):872-6. PMID: 25016388.
This was an observational study of patients with chest pain.
The authors claim that unstructured physician judgment, combined with normal troponin and a normal and non-ischemic
EKG, is sufficiently sensitive to discharge patients from the ED.
Chest pain is a major source of bouncebacks to the ED in
cardiac arrest and malpractice risk in the US. Patients with
acute coronary syndrome (ACS) may have atypical symptoms
and non-diagnostic EKGs. Approximately 2% of MIs are missed
from the Emergency Department. In general, this has led to the
conclusion that physician judgment is not sufficiently accurate
to rule in and rule out MI. Non-judgment-based decision aids,
such as the TIMI or GRACE scores, have been developed but,
in general, are not very helpful. The scores can’t get to the near
100% levels required.
The fact that doctors aren’t perfectly accurate has led to
abandoning judgment in favor of highly technical work-ups,
such as serial enzymes, provocative stress testing, and other
advanced cardiodiagnostics, like nuclear medicine studies
and CT angiography. Combinations of judgment and testing
works for conditions such as pulmonary embolism. Could this
approach work for ACS?
This study looked at if judgment alone works and if not, does a
combination of judgment with EKG and initial troponin work?
They prospectively asked each ED doctor to judge the probability of acute MI on a 5-point scale: from definitely not,
probably not, not sure, probably, to definitely. All of the patients received serial troponins, and the doctor had to make the
assessment prior to receiving the troponin result. Doctors did
have access to the EKG.
The primary outcome was diagnosis of acute MI during patient hospitalization. Secondary outcomes included major
adverse cardiac events within 30 days, defined as death (all
causes), prevalent or incident AMI, and the need for coronary
revascularization. They enrolled 458 patients in the study and
81 (17.7%) were diagnosed with acute MI. An additional 19
patients had a major cardiac event within 30 days.
March 2015: Volume 15, Issue 3 | www.emrap.org
3
What did they find? The performance of clinical judgment alone
was not great. If all patients with an assessment of “definitely
MI,” “probably MI,” and “could be MI” were admitted, or if all patients assessed as “probably not MI” or “definitely not MI” were
discharged, we were only 95% sensitive at detecting MIs. Five
percent of the patients assessed as “probably not” or “definitely
not” MI were later diagnosed with MI. We were only 30% specific.
If the categories of “probably not” or “definitely not” MI were
combined with an initially negative troponin, the sensitivity
improved to 100%. Specificity dropped to 28%. Use of a highsensitivity troponin (not currently available in the US) also had a
sensitivity of 100% and the specificity dropped a little further.
If patients assessed as “definitely not,” “probably not,” and “could
be MI” had a normal EKG and troponin and were discharged, the
sensitivity was still 100% and the specificity was improved.
The authors claim that the study broke new ground by finding that
patients with a negative EKG and troponin, where the physician
did not think the patient had MI, were unlikely to have MI. This
seems fairly obvious. We are pretty good at figuring out who is
having ACS when we have something to augment our judgment.
Remember, this is a derivation study and has not actually
been validated. We don’t know what would happen if the doctors were compelled to discharge the patient and if that might
change their perception of risk of MI. This is not ready for prime
time, but it is a nice idea that we should be allowed to use our
judgment in assessment of ACS.
Obese Patient and Knee Dislocations
Mel Herbert MD interviews James Webley MD
Knee dislocations usually stem from a high-energy mechanism
of injury, such as a car accident or sports. Classically, two-thirds
arrive with the knee already relocated and about 10% will have
damage to the popliteal artery.
Since 2000, there have been a number of reports of patients experiencing knee dislocations with very minor injury mechanisms.
Azar FM, et al. Ultra-low-velocity knee dislocations. Am J Sports
Med. 2011 Oct;39(10):2170-4. PMID: 21757779. This paper
described 17 patients with knee dislocations that occurred during usual daily activities. All 17 patients were obese with an average body mass index of 48. Forty percent of patients sustained
damage to the popliteal artery, and 40% had damage to the
peroneal nerve.
Georgiadis AG, et al. Changing presentation of knee dislocation
and vascular injury from high-energy trauma to low-energy falls
in the morbidly obese. J Vac Surg. 2013 May;57(5):1196-203.
PMID: 23384491. Of the patients who had knee dislocation
due to low energy dislocation, 18 patients were obese with an
4
average BMI of 40. Approximately 40% of these patients had
arterial injury.
Patients who are significantly obese can transmit tremendous
forces on their joints. There is a high rate of vascular injury. You
should be very concerned about this. Patients with knee dislocations should have their vascular structures evaluated. Monitoring
vascular function in the very obese can be difficult due to their
body habitus.
Walking can place a factor of 1.3-5.8x the body weight on the
joint. Running or jumping can place a factor of 6-8x the body
weight on the joint. A 500-pound patient theoretically can generate thousands of pounds of stress on that joint.
In the studies, they often did not realize the patient had a dislocated knee until they saw imaging. Many of the patients with
large BMIs were not relocated prior arrival to the ED. Only one
person had a knee that looked normal on initial films.
Cyanide in the Real World
Howard Mell MD
In the United States, we have moved from traditional, naturalsourced building materials to lightweight, better insulated, petroleum-based materials that give off heat and cyanide when
burned. We are classically taught that smoke inhalation causes
carbon monoxide poisoning. However, when you look at studies
of fire deaths, it is the cyanide that is responsible. Why aren’t we
talking about cyanide poisoning?
We have a good test for carbon monoxide poisoning, and we
have a good treatment: we can start off with oxygen and move to
hyperbaric oxygenation. We know what it is, we know how to test
for it, and we know the treatment is benign.
This is not the case for cyanide poisoning. There are very few
institutions that are able to obtain a cyanide level. Those that
can are often unable to obtain levels fast enough to affect treatment decisions. The standard treatment, the Lilly antidote kit, is
not a benign treatment. It causes methemoglobinemia. We can’t
detect cyanide poisoning, and we can’t treat it well.
The Lilly kit is comprised of three drugs: two nitrites and a
thiosulfate. The nitrites convert the iron in hemoglobin from the
ferrous to the ferric form, creating methemoglobinemia. Cyanide
has a high affinity for methemoglobin and creates cyanomethemoglobin. The cyanide comes off the mitochondria it has
poisoned. The thiosulfate is a sulfate donor, which allows the
enzyme rhodanese to convert the cyanide to a form that can be
renally excreted.
There are a lot of downsides to this therapy. The nitrites can
cause hypotension. We are inducing a methemoglobinemia,
which can lead to hypoxemia. Patients with smoke inhalation
also likely have carbon monoxide poisoning and are experiencing trouble with cellular respiration and oxygen-carrying
capacity; methemoglobinemia will further reduce this.
The Cyanokit contains IV hydroxycobalamin. This is vitamin
B12a and a precursor to B12. This had been available in the
United States for years, with FDA approval for the treatment of
pernicious anemia. The concentrations used to treat pernicious
anemia are not effective in cyanide poisoning, but greater concentrations work extremely well to scavenge the cyanide. This creates vitamin B12. You urinate out the excess B12. This is a safe
drug to give. It has minimal side effects: it causes a transient
hypertension, which is not clinically significant. It makes some
patients turn a red color. These effects improve spontaneously. We
now have a treatment that is easy and safe to give empirically.
events that could be correlated with actual events.
It is well documented that patients receiving general anesthesia
have auditory recall of events and things that happen to them
while they are under. They occasionally have visual recall as well.
Do cardiac arrest survivors recall specific events from their
resuscitation?
The authors conducted a study with extreme methodological rigor
to determine the incidence of awareness and accuracy of reports
of visual and auditory events during cardiac arrest resuscitation.
The study included cardiac arrest survivors over the age of 18
years, who were deemed fit for interview by their physicians and
caregivers. They tried to conduct interviews in the hospital, but
most were done after discharge.
The patient is given a dose of 5 grams over 15 minutes.
It seems to work. What is the downside? It is extremely expensive. The manufacturer packaged it as a concentrated and
freeze-dried formulation that could be reconstituted and given
to firefighters, and the FDA gave it on-label usage.
To assess the accuracy of claims of visual awareness, they installed big shelves in resuscitation areas and each shelf contained an image only visible from above the shelf. They also put a
picture of a triangle on the bottom of the shelf, which the patient
could theoretically see from their vantage point.
The Paris Fire Brigade protocol recommends giving it to patients who have had known smoke inhalation in an enclosed
space with any of the following: altered mental status, soot
in the nares or mouth, or a full arrest without full body burns
incompatible with life. They found 50% ROSC in fire victims in
full arrest when hydroxycobalamin was administered.
They performed three stage interviews using the Greyson Near
Death Experience scale. This includes questions, such as “Did
you have a feeling of peace or pleasantness?” and “Did you feel
separated from your body?”
Fortin JL, et al. Prehospital administration of Hydroxocobalamin for smoke inhalation-associated cyanide poisoning:
8 years of experience in the Paris Fire Brigade. Clin Toxicol.
2006;44 Suppl 1:37-44. PMID: 16990192.
Borron SW, et al. Prospective study of hydroxocobalamin for
acute cyanide poisoning in smoke inhalation. Ann Emerg
Med. 2007 Jun;49(6):794-801, e1-2. PMID: 17481777.
We need to consider using this even though it is expensive.
The prehospital death rate from cyanide is excessive, and we
now have a safe treatment.
Paper Chase 3:
Do Dead Patients Remember
Being Resuscitated?
Parnia S, et al. AWARE – AWAreness during Resuscitation – a
prospective study. Resuscitation. 2014 Dec;85(12):1799-805.
PMID: 25301715.
Overall, they had 2,060 cardiac arrest events and about 330
survived to hospital discharge. They interviewed just under half
(140 survivors). About 40% reported remembering something
about their cardiac arrest but the vast majority were vague
recollections. Many patients alluded to themes, such as fear or
violence and persecution. The study included quotes from survivors, such as “Being dragged through deep water.”
Only 2 patients out of 55 with memories of the event remembered specific things. They were able to verify one of these. It
was unrelated to the shelf, although about 80% of the resuscitations happened in rooms without the shelf.
The experience of cardiac arrest patients differs from those
experiencing general anesthesia. This makes sense as the
brain is asleep versus dead. The sample was too small to see if
these recollections can relate to the development of post-traumatic stress disorder (PTSD).
Most patients won’t remember the events of their cardiac arrest but there are some who will. In addition, family members,
social workers, nurses, and other patients may be aware, so act
professionally.
This is a multi-national cohort collected over 4 years of survivors of cardiac arrest. They reported that 40% of these patients
had some memory of their resuscitation. Most recollections
were theme-based and only 1 patient was able to recall specific
5
Community Medicine Rants:
Vapotherm
Al Sacchetti MD and Tom Miller PhD from Vapotherm
Sacchetti has been using the high-flow, high-humidity (HFHH)
oxygenation via nasal cannula more frequently. Recently, a
patient with pulmonary fibrosis presented peri-arrest. He was
placed on HFHH therapy and he improved rapidly.
How does the physiology of ventilation in infants differ from
adults? If an adult breathes in a tidal volume of 500mL, approximately 150mL will be dead space containing high levels
of CO2 and low levels of oxygen. The patient inhales the 150mL
of dead space followed by inhaled gas with each breath. Infants
have a proportionally larger dead space of approximately 4mL/
kg, which can be equivalent to their entire tidal volume of 4-6ml/
kg.* When they breathe in, they mostly inhale the gas that is
waiting in the conducting airways for exhalation. Infants are more
dependent on expiratory and inspiratory gases mixing in the airways to oxygenate. They regulate the flow rate in the pharynx so
the air they exhale and inhale mixes, allowing them to dilute the
carbon dioxide and increase the oxygen.
* Editor’s Note: One small study noted anatomic dead space of
3.3mL/kg in early infancy, compared to 2.2mL/kg in adults.
PMID: 8727530.
of the mucus and paraciliary water layer may assist the mucus
transport system to loosen and clear secretions. This can also help
adults with conditions complicated by secretions, like bronchiectasis or pneumonia. This may also be useful in asthmatics.
The device washes out about a third of the adult’s anatomical
dead space, blowing out CO2 that would otherwise be re-inhaled
and replacing it with a greater volume of oxygen. In healthy volunteers, this leads to a decrease in breathing effort of about
15%, without a change in tidal volume. It is not a CPAP system
but does provide about 3-4 cm of resistive load during exhalation, which is equivalent to pursed lip breathing. This can benefit
patients with COPD.
Mizuho Files:
Ask the Trauma Surgeon
Mizuho Spangler DO interviews Kenji Inaba MD
Can you tamponade bleeding from pelvic fractures by inflating a balloon in the bladder or not emptying it? This probably wouldn’t work, as the bladder sits anteriorly in the pelvis
and most bleeding occurs in the posterior area where the venous
plexus is located. The bladder is unable to expand sufficiently and
wouldn’t be able to compress bleeding in the posterior pelvis.
How do you use the high-flow therapy? Sacchetti will place
the nasal cannula on the patient and start with an initial rate of
approximately 30L/min. He then titrates the FiO2 to the desired
oxygen saturation.
There is a group at Massachusetts General Hospital that is doing research on a percutaneously-introduced self-expanding
foam into the abdomen, to tamponade bleeding until the
patient is able to have laparotomy for definitive hemorrhage
control. However, this is not ready for primetime.
The HFHH nasal cannula differs from conventional oxygen
delivery systems. You are not delivering pure oxygen, but rather
whatever blend of oxygen that you want patients to receive. In
addition, flow rates and flow dynamics can be used to wash out
and purge the nasopharyngeal cavity of carbon dioxide between
breaths. When patients take a breath through the nasal cannula,
they breathe in the gas mixture you control. The CO2 drops and
the oxygen increases in the nasopharyngeal cavity.
Pelvic binders, like a sheet or T-pod, likely splint and stabilize
the pelvis and decrease pain, making transport easier but
probably don’t tamponade bleeding in the pelvis. The structure of the pelvis is like an empty cone and the bleeding into
the retroperitoneum occupies a small area of the lining of the
cone. External compression alone is probably not sufficient to
tamponade bleeding.
Set your flow and set your O2. You want to set your flow at
a rate that will accomplish your objective of purging the pharyngeal space. This is usually between 25-35 L/min in most
adults. Patients who are in bad shape can tolerate flow rates
of 40 L/min. Once they are improving, you can titrate down
the rate. Titrate the FiO2 to whatever gets you to the desired
oxygen saturation. The oxygen fraction that they are inspiring
isn’t dependent on the respiratory rate, unlike conventional
nasal cannulas or face masks.
The ability to condition and humidify the gas prevents damage to the nasal mucosa and condensation in the tubing.
Use of HFHH nasal cannula in children with bronchiolitis. Pediatric patients with RSV have a problem with mucus. Humidification
6
REBOA (Resuscitative Endovascular Balloon Occlusion of
the Aorta) is a promising avenue of research. This involves
percutaneous introduction of an inflatable balloon that occludes the aorta above the site of pelvic bleeding, until the
patient is able to receive interventional radiology or intraoperative packing. Data should be available in the next year or two.
What is the theory behind permissive hypotension in trauma?
It is thought that patients will form some clot in areas of bleeding
at non-compressible sites, and IV fluid administration can artificially elevate the pressure and pop the clot. Also, fluids administered may dilute the coagulation factors, platelets, and oxygen
delivery capacity of the red blood cells, making it difficult for the
clot to reform.
The pre-clinical work done prior to the Bickell study showed
that this may be true, at least in the animal models.
on in-hospital mortality. J Trauma. 2002 Jun;52(6):1141-6.
PMID: 12045644.
Bickell WH, et al. Immediate versus delayed fluid resuscitation for hypotensive patients with penetrating torso injuries. N
Engl J Med. 1994 Oct 27;331(17):1105-9. PMID: 7935634.
This paper included 598 patients with penetrating trauma to
the torso only. Patients who were moribund were not included.
They excluded patients who did not receive operative intervention to the torso, abdomen, neck, or groin. Patients all had
a systolic blood pressure of less than or equal to 90mmHg.
Patients were pseudo-randomized to odd versus even days
and received either standard fluid resuscitation or minimal
fluid resuscitation with IV placement only.
Morrison CA, et al. Hypotensive resuscitation strategy reduces
transfusion requirements and severe postoperative coagulopathy in trauma patients with hemorrhagic shock: preliminary results of a randomized controlled trial. J Trauma. 2011
Mar;70(3):652-63. PMID: 21610356.
They found improved survival, which is difficult to show in
any trauma study given the heterogeneity of the patients.
The survival rate improved from 62% to 70%. The complication rate decreased from 30% to 23%.
This is an interesting study that showed that we probably don’t
need to resuscitate everyone to a normal blood pressure.
However, this was in a very limited patient set. They excluded patients with minor injuries (about 30%); patients had
to have received a thoracotomy, laparotomy, and neck or groin
exploration. We often don’t know on arrival if a penetrating
trauma patient will need to go to the OR for operative intervention. We may give a fluid challenge to assess response;
if the patient responds, he/she may fall into the category of
patients who were excluded from the study.
This study was performed using the EMS system in one
city. The time on scene was short and transport times were
short (about 12-13 minutes). This may not apply in rural areas with longer transport times.
Our approach to resuscitation has changed since this
study was performed. In the prehospital phase, patients in
the immediate-resuscitation group received an average of
870mL compared to 92mL in the delayed resuscitation group.
At the trauma center, they received 1608 mL compared to
283 mL. Now, we give a small amount of crystalloid as a challenge and then move to blood. It is hard to know if this applies
to the patients we see today.
The average blood pressures in the two arms of the study,
prior to transport to the OR, were 112 mmHg and 113
mmHg, despite the fact they received markedly different
resuscitation schedules. Was crystalloid or fluid restriction
beneficial?
This study has not been replicated or validated.
The study by Dutton did not show any difference. Dutton RP, et
al. Hypotensive resuscitation during active hemorrhage: impact
Patients in hemorrhagic shock, who required emergent surgery, were randomized to a hypotensive resuscitation strategy
(target MAP of 50 mmHg) or a control group of standard fluid
resuscitation (target MAP of 65 mmHg). Patients were followed up for 30 days. They were not able to show significant
difference in mortality by 30 days.
This is not a huge difference in blood pressure.
Patients in the restrictive strategy group received significantly less
blood products and total IV fluids. This is probably important.
They showed that this is a relatively safe strategy.
What do we do today? If the patient presents with a clear source
of bleeding and is clearly going to the operating room, it is okay
to not resuscitate them fully to a normal blood pressure. Once
you have made the diagnosis that there is something going on
that requires intervention in the operating room, the goal should
be on getting the patient to the operating room to stop the bleeding. Once you have control of the bleeding, you can adequately
resuscitate them.
A patient who presents with hypotension, penetrating
trauma, and a positive FAST, and who is going immediately
to the OR, does not need to be resuscitated to a blood
pressure of 120 mmHg or more prior to transport. The best
target pressure is unclear; a target of 90mmHg or adequate
mentation in a patient without associated brain injury may be
sufficient.
For everyone else, such as in prolonged transport time,
transfer to a trauma center, or traumatic brain injury, restrictive resuscitation is probably not applicable. The goal
should still be on surgical control as quickly as possible. For
traumatic brain injuries, we should resuscitate them to the
point where their brain is perfusing the best.
Restrictive resuscitation does not apply in the hypotensive patient with a negative FAST and normal or borderline hemoglobin. These patients still warrant resuscitation:
administer a small amount of crystalloid and move quickly to
blood products. We should aggressively look for a source of
bleeding. If they plateau, then you have the time to do a good
diagnostic work-up.
What is the role of EMS-based blood and blood product resuscitation? This is actively being studied.
7
The PROPPR study has completed enrollment of patients and
is beginning to compile data. This should provide more information about the most appropriate resuscitation strategy with
blood products in the Emergency Department.
* Editor’s note: The PROPPR study just published in February
2015! PMID: 25647203.
In summary. Work with your trauma surgeon at your facility; it
might be site-specific to even consider hypotensive resuscitation. There is not enough information on blunt trauma. Hypotensive resuscitation may be appropriate in the right patient where
the goal should be on rapid transport to the OR. For other patients, appropriate ratios of blood products, administering blood
products early on in resuscitation, and minimizing crystalloids
are probably most important for patient care right now.
Paper Chase 4:
CT Screening for Pediatric Neck Injury
Desai NK, et al. Screening CT angiography for pediatric blunt
cerebrovascular injury with emphasis on the cervical “seatbelt sign.” AJNR Am J Neuroradiol. 2014 Sep;35(9):1836-40.
PMID: 24722311.
For pediatric patients in a motor vehicle collision, the presence
of an isolated seatbelt sign was not associated with any cases
of cerebrovascular injury.
Cerebrovascular injury is very uncommon in blunt trauma and
affects approximately 1-2 out of 300 cases. However, it has
some features that are very scary. Patients with it may be asymptomatic at the time of the injury but may progress to large and devastating hemispheric strokes several days later, after propagation
of the thrombus and occlusion of the injured vessel. The average
time for development of symptoms is 72 hours, if the patient is asymptomatic on arrival. Should we be screening for these patients?
The latent period might justify screening if there was a proven
therapy that could prevent the stroke before it happened. There are
some studies that suggest a lower incidence of injury with screening but it is unclear if there is a therapy that improves outcome.
Trauma surgeons have developed some screening guidelines
that include: pulsatile bleeding from oropharynx, nose or ear;
lateralizing neurologic symptoms in patients less than 50 years
old; hanging injuries; basilar skull fractures; low GCS with diffuse
axonal injury; severe facial fractures; and high cervical spine
fractures. Concern persists about what to do when there is a
bruise or scrape over the neck in isolation.
The EAST group (Eastern Association of Trauma Surgeons) does
not say anything about seatbelt sign while the WEST group
(Western Association of Trauma Surgeons) lists isolated seat belt
sign as a high-risk feature for blunt cerebrovascular injury.
8
This study looked at whether the seat belt signs had any
predictive ability in detecting blunt cerebrovascular injury in
kids. The methods of the paper aren’t strong. It is a retrospective
chart review with not great data quality, but it is an important
issue. They looked at all the CTAs performed on children over a
10-year period. These were divided into traumatic versus nontraumatic. They were interested in the blunt traumatic injuries
that occurred due to motor vehicle accident.
They included 82 children who were in a motor vehicle accident
and had a CTA. Of the 82, 42 had a documented seatbelt sign.
None of the children with a seatbelt sign had a blunt injury.
However, 3 of the 40 children without a seatbelt sign had injury.
Twenty-two of the patients had some type of soft-tissue injury to
the neck that was not described as a seatbelt sign. One of these
patients experienced blunt cerebrovascular injury, but this child
was severely injured with a GCS of 3, had a high cervical spine
injury, and died.
This is a small study and not great. However, of the 42 patients
with a cervical seatbelt sign and of the 22 patients with some
other soft tissue injury, nobody had a blunt cerebrovascular
injury in isolation. This argues against scanning children for blunt
cerebrovascular injury based on seatbelt sign alone. However, this
is a small study and the data is not there yet. You will have to use
your clinical judgment and institutional experience, but it is not
unreasonable if you don’t scan these children.
Airway Corner:
Psychology of Airway Management
Darren Braude MD interviews Richard Levitan MD
Case #1
You are working in the Emergency Department when an
obese patient with some risk factors for a difficult airway
presents with hypoxia. You are on the fence about whether
or not to intubate the patient. Consultants are involved and
the decision is made to intubate the patient. The drugs have
been pushed and the intubation is not going well. You are
starting to feel panicked. How does psychology influence
what is going to happen?
This is performance stress. The perception of your ability to
meet the perception of the demands leaves you uncomfortable.
To perform well under pressure, you need to accept the reality
and responsibility: you make a decision and you go with it. If you
are indecisive to begin with, it is a bad way to start. Once you are
in, you need to be all in. You need to accept responsibility for the
situation and be convinced you are doing the right thing. “This
has to happen and it has to happen now. I am the one doing this
and there is no help coming.”
We need to be conscious of our self-talk. In performance
psychology, there is a concept called “STEP UP” (Self-Talk for
Enhanced Performance Under Pressure). This requires positive
language and terminology. If you tell yourself, “This is not going
well. I’m not going to get this. I never should have intubated this
guy,” you will not perform well. You are emphasizing the demands
of the situation and downplaying your abilities.
If you are hesitant, it affects the rest of the team. “Ok guys,
here is the plan. We are going to do this, this, and this. If it
doesn’t work, we are going to do X, Y, and Z.” By verbalizing aloud,
it gives everyone an understanding of the plan.
You can say to yourself, “I’ve thought about the options. This
is in the best interest of the patient.” Go through self-talk scenarios. Imagine the teachers who have taught you standing behind you. Visualize the anatomy of the airway.
What should you do if things aren’t going well?
Focus on small steps. In crisis, people don’t do well when
looking at the big picture.
First step is to focus on the oxygenation: positioning, nasal
cannula, non-rebreather, bag-valve-mask with PEEP, or CPAP.
Then, ask the nurse if he/she has the drugs. “Ok, we are going to push the drugs, and we are going to wait 60 seconds. I
want you to time it.”
Break the procedure down into a one-step progression.
Keep AAADA in the back of your mind: Alert, Assessment, Anticipation, Decision and Action.
In your head, continue positive self-talk. “Ok, I’ve maximized
oxygenation and positioning. Here is my plan.” Imagine the
landmarks as they come into view. Imagine the success of
managing the airway.
Say to yourself, “If this doesn’t go well, I have an LMA. I have
an I-gel. I have a fiberoptic instrument and video laryngoscopy. I know what the surgical landmarks are.”
Military aviation developed the OODA loop: Observe, Orient, Decide
and Act. The psychologist Dr. Michael Asken has modified this to
AAADA: Alert, Assessment, Anticipation, Decision and Action.
Alert. Alert to potential problem. “This patient may have intrinsic laryngotracheal pathology and require a surgical airway.”
Assessment. What does his voice sound like? Can he phonate? What is his oxygenation status?
Anticipation. Find the larynx and mark it with a pen. Know
where the surgical airway is.
Decision. You decide to cut the neck.
Action. You do it.
Multitasking is a myth. Focus on the next step. Levitan recently sat next to a pilot who shared a story of a crisis experienced while flying. He was the First Officer and taking off from
a crowded airport in a plane carrying 200 passengers, when he
lost the use of one of his two engines, 50 feet from the ground.
This can cause the plane to yaw and travel in one direction, due
to the thrust off of only one wing. He wasn’t at an elevation high
enough to turn the plane around. A series of actions was required immediately.
“The big picture was too depressing. Instead of focusing on
that, I focused on the next task at hand.” He told the pilot to
fly the plane straight. He pushed the thrusters forward on the
single functioning engine and reminded himself that a single
engine can carry the plane up. Then he went through the steps
of a check-list.
It is important to have checklists, whether printed or mental,
so that you can focus on the small steps, without having to
rely on memory when you are stressed.
Take responsibility. Commit and focus on managing the situation.
Imagine success. Reassure yourself that you have the ability to
do this. You have the training to do this. You have the resources
and the tools. Think one step at a time: where you are and what
you need to do next.
How does performance stress affect you?
It can cause you to grip the laryngoscope too tightly and
smush it against the tongue in the middle. Then you can’t
sweep the tongue. If you bypass the epiglottis, you won’t see
anything. Hold the laryngoscope with two fingers. You are
aiming for 2-3 lbs. of pressure lifting the tongue and jaw.
You are looking for the epiglottis, not doing the intubation.
Then, follow with progressive landmark exposure.
We bag people too quickly when we are stressed. Place one
hand on the bag and the other hand on the face to maintain patency.
Try to slow down the tube delivery and avoid ramming the
tube in there.
Remember to breathe.
Notes From The Community:
Rethinking the APAP Nomogram
Rob Orman MD interviews Bryan Hayes PharmD
At the recent meeting of the North American Congress of
Clinical Toxicology, a poster was presented that highlighted
some concerns about the current use of the APAP nomogram.
Rarely, a serum acetaminophen level drawn four hours after overdose will be less than the nomogram line, indicating the patient
9
is not a candidate for treatment with N-acetylcysteine. However,
a second level drawn at 8 hours is over the line and deemed a
toxic ingestion. These patients are referred to as “line crossers.”
The Nebraska Poison Center described three cases where
the 4-hour acetaminophen level was non-toxic, but a second
level drawn at 8 hours did reach toxic levels. All patients were
treated with N-acetylcysteine and none developed liver injuries.
These cases seem to be in situations where the acetaminophen is
ingested with a second agent that slows GI motility, such as acetaminophen-diphenhydramine or acetaminophen-opioid products.
Case reports have described this phenomenon. Dougherty PP,
et al. Unexpected late rise in plasma acetaminophen concentrations with change in risk stratification in acute acetaminophen
overdoses. J Emerg Med 2012;43:58-63. PMID: 21719230.
Several poison centers are recommending that co-ingestions with a
medication slowing GI motility receive a second level 8 hours later.
All of the reported cases were treated with N-acetylcysteine and
did well. We don’t know what would have happened if they didn’t
receive treatment after the 4-hour level was within the limit.
For extended-release acetaminophen, acetaminophen with
diphenhydramine, and acetaminophen with any opioid (such
as oxycodone or hydrocodone), consider getting a second
level at eight hours.
Care with N-acetylcysteine is more individualized now than
previously. Patients receiving treatment with labs below certain
levels may be able to stop treatment earlier. Patient, who are sick
with a high degree of liver dysfunction, may receive N-acetylcysteine for longer than the 21-hour infusion.
This is a small case series. The nomogram still works, but it is
possible that there is a caveat and your poison control center
may adjust management accordingly.
Notes From The Community:
MACS Decision Rule, High Sensitive Troponin,
and Cardiac Risk Factors
Rob Orman MD and Richard Body MD
Having multiple risk factors increases the risk of cardiac disease in general. A diabetic, hypertensive patient, who smokes
two packs of cigarettes a day and is presenting with chest pain,
is going to raise an alarm for acute coronary syndrome (ACS).
What about a 50 year-old patient with no cardiac risk factors
and chest pain? Does the absence of cardiac risk factors reduce the likelihood of this chest pain being due to ACS?
There is no doubt that patients with multiple cardiac risk factors have an increased risk of coronary artery disease over many
years. However, we are looking at patients in the Emergency De-
10
partment and trying to determine their risk of acute myocardial
infarction. Whether or not the absence of risk factors rules out
ACS is a very different question. The Framingham study never
said that if you don’t have any risk factors, you won’t go on to
develop coronary artery disease. You can have no cardiac risk
factors and still develop coronary artery disease.
Body R, et al. Do risk factors for chronic coronary heart disease help diagnose acute myocardial infarction in the Emergency Department? Resuscitation. 2008 Oct;79(1):41-5.
PMID: 18691797.
The study found that the absence of any traditional cardiac
risk factors carried a negative likelihood ratio of 0.61 for the
diagnosis of acute myocardial infarction (AMI). The study
concluded that traditional cardiac risk factors are not helpful
for the confirmation or exclusion of AMI. However, there are
chest pain protocols and decision rules that use instruments,
such as Framingham cardiac risk factors, TIMI score, or HEART
score, which incorporate cardiac risk factors.
The probability decreases slightly if you have no cardiac
risk factors (from 18% to 12%) but it does not mean you
can’t have acute MI. You are not going to rule out patients
based on absence of risk factors.
This paper can help us convince admitting physicians that patients without risk factors can have ACS. It can also help us
stop over-treating patients with multiple cardiac risk factors.
The TIMI risk score was derived from a population of patients
with confirmed acute coronary syndrome, not undifferentiated chest pain in Emergency Department patients. It was
designed to predict outcome in confirmed ACS.
Risk factors are also included in the HEART score (history,
EKG, age, risk factors, and troponin). This was derived based
on the opinion of AJ Six, a cardiologist, based in the Netherlands.
There was no evidence that risk factors made a difference.
Patel H, et al. Myth: identifying classic coronary risk factors
helps to predict the likelihood of acute ischemia. West J Med.
2000 Dec;173(6):423-4. PMID: 11112767.
They also found that classic coronary risk factors were not
predictive of acute ischemia.
Body R, et al. Rapid exclusion of acute myocardial infarction
in patients with undetectable troponin using a high-sensitivity assay. J Am Coll Cardiol. 2011 Sep 20;58(13):1332-9.
PMID: 21920261.
They found that an undetectable troponin T level, upon presentation, has a very high negative predictive value. An undetectable troponin T level may be considered to rule out AMI,
identifying patients at low risk of adverse events. The negative
predictive value was close to 100%. However, this is at the
expense of specificity. There will be a lot of false positives in
patients without acute MI.
High-sensitivity troponins addressed the need for an early
marker that could give us a definitive answer when patients
arrived in the ED, rather than several hours later. They also
addressed the need for a way to detect patients with unstable
angina, who were standard-troponin negative, but would go on
to experience cardiac events.
It raised the question whether or not you could lower the cut-off
and use it to rule out acute MI. If you lower the cutoff, you will
increase sensitivity and negative predictive value. They set the
cutoff the level as low as possible. This results in more false
positives. However, in the study, patients with greater than undetectable levels were not labeled as positive; they just weren’t
ruled out for AMI. They were still in the observational zone.
What is the probability of MI, if the patient has suspected
cardiac chest pain and a positive high-sensitivity troponin
assay? 50%.
This doesn’t mean that the high-sensitivity troponin is a bad
test. We still have incomplete information. We don’t know
whether the level is rising and falling. The troponin is not a
simple dichotomous test either; you will be much more concerned in a patient with a troponin level >15,000, than a
troponin level barely above the cutoff. A positive test is not the
same thing as a positive diagnosis. It is one piece of information utilized by the physician in making a diagnosis.
ate analysis. The rule contains 8 variables including: high
sensitivity troponin, heart-type fatty acid binding protein
(another biomarker), worsening angina, ECG ischemia,
pain that radiates to the right arm or shoulder, diaphoresis, vomiting, and a systolic blood pressure <100mmHg.
There is no single diagnostic cutoff for the biomarkers: the
higher the level, the higher your risk.
The rule was derived in just over 700 patients and externally
validated in another study of over 500 patients.
The final decision rule divided the patients into the four
risk group categories. In the very low risk group (just over
25% of patients), there were no missed MIs and a very low
rate of adverse cardiac events within thirty days (1.6%). There
were two adverse events: both were patients with coronary artery stenosis detected on outpatient angiography and neither
required intervention. The high risk group was essentially ruled
in: 91% had acute MI and just over 95% experienced adverse
cardiac events.
Los Angeles Marathon Clinical Lessons
Stuart Swadron MD Clare Roepke MD and Oma Knox MD
Approximately 25,000 runners participate in the Los Angeles
Country marathon yearly. The LAC+USC Emergency Department
provides medical care in 10 tents along the marathon route. In
2013, they treated 1,300 patients along the course. In 2014,
they treated approximately 3,500 runners.
High-sensitivity troponins have been used in England for several
years. Body looked at database results for 6 months prior to implementation of the high sensitivity troponin and 6 months afterwards. They found that the proportion of patients with a positive
result increased from 18% to 32%. If this is stratified by age, nearly
75% of patients over 75 years had a positive troponin assay.
There were 654 marathons in the United States in 2012 with
529,000 runners. Many of these patients will wind up in the
closest Emergency Department or Urgent Care.
Body R, et al. The Manchester Acute Coronary Syndromes (MACS)
decision rule for suspected cardiac chest pain: derivation and
external validation. Heart. 2014 Sep 15;100(18):1462-8.
PMID: 24780911.
These are the injuries you might expect: sprains, Achilles tendon rupture, etc. Many of these athletes have been training
intensely for the event.
This decision rule was designed to identify very low risk
chest pain patients and avoid unnecessary admissions.
There are four risk groups and each risk group is associated with a suggested course of action. The very low risk
group is discharged home. The high risk group is admitted to
the coronary care unit or high dependency environment with
involvement of cardiology. The moderate risk group is admitted
to an acute ward, such as the medical admissions unit. The low
risk unit is admitted to Emergency Department observation.
The clinical decision rule was derived from clinical information such as symptoms, past history, risk factors, EKG findings,
and biomarkers. They derived the MACS rule using multivari-
What are some common complaints of marathon runners?
Musculoskeletal cramps and pain.
Musculoskeletal cramps are grouped into three categories.
The least significant, but probably most common, is a single
muscle cramp or muscle group, such as a right calf muscle.
These patients should be treated with assisted walking or
independent walking. Highly competitive athletes will not
want any assistance, as they do not register a time if they
are helped to the finish line. These patients do not require
transport for evaluation.
The second category is repeated cramping. For example, the
left calf muscle cramped at mile 5, 10, and 15. Now it is
cramping and won’t stop. These patients are likely experiencing
electrolyte or dehydration problems. The treatment is oral hydration, a calorie resource, and either assisted or independent
11
an i-STAT available to check electrolytes. Some international
races stock hypertonic saline but most do not. You can start
administering normal saline in the absence of hypertonic.
Most paramedic rigs in the United States are able to administer benzodiazepines.
walking. There is no standard for oral rehydration techniques.
Once their cramps have resolved, they can resume the race.
If patients are unable to ambulate unassisted, or are collapsing due to involvement of multiple muscle groups, they will
need IV fluid rehydration and possibly benzodiazepines. Consider giving magnesium intravenously if available. However,
medical staff at most races will not be able to administer
magnesium, as it requires a pump. For these cases, transport
to a higher level of care may be a better option.
Chafing and blisters. Some runners are prone to this even prior
to starting a race. Patients who are new to running or those who
are overweight with thighs rubbing together. Cotton t-shirts can
chafe nipples. The treatment includes putting Vaseline on the
wound or chafed area. The area can be protected with moleskin
or a Band-Aid. Moleskin can be very helpful for blisters, especially between the toes, and allow runners to continue.
Life-threatening events are rare. In the Los Angeles marathon
this year, there was one cardiac arrest that occurred mid-route.
The patient was treated with the ABCs and ACLS, the paramedics were involved and the patient was transported to an
Emergency Department and survived. They saw a few altered,
somnolent patients who collapsed at the finish line and had
sustained heat stroke. These patients had core temperatures
checked immediately, and active and passive cooling measures were initiated if elevated. These patients were transferred.
About 1 in 10,000 marathon runners will experience heat
stroke. These patients will be transported from the marathon
to your Emergency Department.
The collapsed runner. When you approach an unconscious patient, start with the ABCs.
12
GI emergencies in marathon runners.
The most serious condition in a collapsed runner is a cardiac
event. Patients in their 20s and 30s may experience some of
the conditions typically associated with younger patients, such
as HOCM or tachyarrhythmias. You need to initiate CPR. Remember that most tents along the marathon route will not have
a defibrillator and you will need paramedics to defibrillate.
Cecal volvulus in marathon runners. This is thought to occur traditionally in the 25 to 35 year old age range. These
are endurance athletes. They will present with symptoms of
obstruction, such as acute abdomen, vomiting, bloating, and
toxic. The abdominal x-ray looks like a coffee bean. This is a
surgical emergency.
If the patient has a pulse but is altered, check a core temperature. This is a rectal temperature obtained in the field. Hypothermia and hyperthermia can present similarly with altered mental
status in the collapsed runner. If the patient is either too hot or
too cold, they need to be transported, as these are conditions
that you are not going to be able to manage well at the scene.
If the patient is hyperthermic, you need to cool them. You can
use ice packs to the axilla or groin. You can submerge the patient in ice water. Spray bottles with tepid water can be used
to passively cool them. Expose the patient and remove the
wet clothing to allow evaporative cooling. Shivering can cause
heat retention. Make sure to check the glucose.
While running a race, about 80% of the normal blood flow
leaves the gut. Many of these patients will be vomiting. Use
your clinical judgment. Are they distended? Do they look obstructed? Are they persistently vomiting despite your treatments? You don’t want to miss a cecal volvulus but you also
can’t transport everyone who is vomiting. Eighty percent of
marathon runners will vomit by the end of the race.
Bright red blood per rectum. This is common in marathon
runners. Sixteen percent of race participants will have hematochezia or bloody diarrhea within 24 to 48 hours of the race.
This is normal. Eighty-five percent of runners will be guaiac
positive but it is not clinically significant. Unless they look like
ischemic colitis with a tender abdomen and ill-appearing, you
don’t need to work it up further. Remember, these patients are
all going to look sick initially: they will be diaphoretic, pale,
dehydrated, etc. They just ran twenty-six miles. Observe them
to see if they continue to look ill.
Hypothermic patients need to be exposed and dried off. Wrap
them in a towel or blanket. They need to be dry and out of the wind.
If the patient is normothermic, consider hyponatremia and
hypoglycemia.
Hyponatremic is difficult because they are altered, confused
and sick. They may seize. It is important to remember that
patients with epilepsy may be running in the marathon and
not all seizures are hyponatremic. Tents along the marathon
route will not have the capability to manage these patients;
you need to get paramedics involved. Some races may have
Cardiac biomarkers. Troponin will be elevated in all these patients. Look at the EKG and the patient, and trend troponins if
clinically indicated. Some of the patients will be having MIs. All of
these patients will have an elevated CK. Most will never be seen
because they self-treat. Unless they are ill and getting admitted,
checking the CK probably won’t make much difference.
Opioid Prescribing Dependency
Jessica Mason MD interviews Joan Papp MD
Papp helped pass a law in the state of Ohio that expands
naloxone access to family and friends of those at risk of overdose. It also provides immunity from drug offenses for those who
administer naloxone in good faith.
How much of a problem is opioid dependency? It is a major
problem. In January of 2012, the Centers for Disease Control
(CDC) published a grand rounds report titled, “Prescription Drug
Overdoses - a U.S. Epidemic.” In 2007, there were 27,000 unintentional drug overdoses in the United States, or 1 death every
19 minutes. Prescription opioid abuse is a driving factor in this
increase in mortality. It has started to gain national attention.
In June, the US Attorney General hosted a White House summit, hosting experts in the field of addiction and pain management. They discussed key strategies to control the epidemic,
including take-home naloxone.
How common is it for patients to transition from addiction to
narcotic pain medications to heroin use? Many people who become addicted to prescription pain medications rapidly become
unable to afford them on the street. Prescription narcotics are
expensive, whereas an equivalent dose of heroin may cost $5-10.
Cicero TJ, et al. The changing face of heroin use in the United
States: a retrospective analysis of the past 50 years. JAMA Psychiatry. 2014 Jul 1;71(7):821-6. PMID: 24871348.
Patients who began using heroin in the 1960s were mostly
young men whose first opioid of abuse was heroin (80%).
More recent heroin abusers report that they were first introduced to opioids via prescription drugs (about 75%).
What is a responsible approach to patients with painful conditions in the Emergency Department? This includes looking
at all of the data available to us. We have the opportunity to
review their medical charts and prescription-monitoring program
(PMP) reports. We have the opportunity to watch their behavior
for several hours in the Emergency Department. These can help
us formulate a plan and determine if they are at risk of or experiencing dependency issues with opiates.
The PMP is a program administered by the state pharmacy
boards and allows a physician to access an individual’s prescriptions for the past 12 months. Some allow you to see prescriptions filled in other states as well.
What are red flags? Look at the total morphine equivalent dose
(MED) the patient is receiving. Over 100 MED is at higher risk
for overdose. Also, look at the number of prescriptions they have
received and the number of providers.
Drug seekers have a diagnosis that carries a high degree of
morbidity and mortality. Substance abuse is a medical condition. A lot of patients started on their path of addiction due to
medications we gave them.
For every death due to prescription abuse: there are 10
treatment admissions for abuse, 32 Emergency Department visits for misuse or abuse, 130 people who are abusing or dependent on prescriptions, and 825 non-medical
users of prescription opioids. We have a unique opportunity
for intervention in the Emergency Department.
How do you approach the conversation with patients, when you
are concerned about an opiate dependency issue? This can be
very difficult. Let them know you are concerned. Approach the patient with an “out,” such as some information that supports your
concern. “Look, I’m really concerned about you. It’s not uncommon
for patients who have received prescriptions for opioids to develop
dependency, even when those opioid prescriptions are used as directed by their physician. Sometimes these prescriptions can lead
to addiction. This may be going on with you. If that is the case, we
would like to help you and offer you some options.”
What can you do besides offer them information on where to
seek treatment for their opioid addiction? Papp offers takehome naloxone kits for individuals at high risk. In the kit are
two doses of intranasal naloxone and information regarding risk
factors for overdose (how to recognize an overdose and how to
respond to an overdose, by administering naloxone and calling
911). This is a medication that has to be given by a third party
to be effective, and they try to engage family members. The kit
includes a DVD with training, and they encourage patients, who
are alone in the ED, to share the information with friends or family members who could help them in the event of an overdose.
What is the nasal adapter? This is an atomizer that attaches
to the end of the syringe. This allows you to spray the naloxone
easily into the nares.
What if you don’t work in an area that has a naloxone distribution program? Can you make your own kit? This is fairly easy
to do for any doctor in the ED. It costs about $50. The American
College of Emergency Physicians (ACEP) also compiled a webinar discussing ways these programs can be implemented in the
ED. A new autoinjector, Evzio, was just approved. It will be available this summer via prescription.
What alternative could you offer a patient with pain but concern for dependency? Buprenorphine. This is an injection medication that is a partial opioid agonist. It is helpful for patients
with concern for opioid dependency because it doesn’t provide
the euphoria associated with morphine or hydromorphone. It can
help with pain in patients without dependency issues.
13
Paper Chase 5:
High Dose Propofol For Peds Sedation
Young TP, et al. Pediatric procedural sedation with propofol
using a higher initial bolus dose. Pediatr Emerg Care. 2014
Oct;30(10):698-93. PMID: 25272069.
This a prospective observational study where the authors report
their experience using a higher initial bolus dose of propofol of
2mg/kg for pediatric procedural sedation. They state that it is
safe and provides high satisfaction, although they don’t address
whether it is better than using 1mg/kg.
We all use propofol and think it is safe. However, the way we
use it varies among physicians. Some like to titrate it, others
give the same initial bolus dose. Some give a different bolus
dose depending on situation. Most physicians seem to use 0.75
mg/kg to 1 mg/kg. This was data collected over a 5-year period.
There were no protocols. The doctors recorded the indication
for sedation and other medications given during the sedation.
They recorded the patient’s weight and initial and total propofol
doses, as well as whether desaturation/hypoxia, apnea, nausea,
vomiting, hypotension, or bradycardia occurred. They recorded
satisfaction on a 100-point VAS scale.
The Annals of Emergency Medicine:
Uremic Frost
Paul Jhun MD and Pablo Aguilera MD
Case #2
A 26 year old man with hypertension and end stage renal
disease presented to the Emergency Department with worsening shortness of breath over the past 2 weeks. He was
visibly dyspneic with difficulty speaking. He was alert but
slow to respond to questions. He reported that he stopped
attending dialysis 3 weeks prior, as he was concerned the
dialysis staff was stealing his blood. He was noted to have
white flaky material on his scalp. His blood urea nitrogen
level was 249 mg/dL. What was going on?
This image was
published in
“Annals of Emergency Medicine,
Volume 65, Issue 3,
Brenner A, Rogers
R, Uremic Frost,
Copyright Elsevier
2015.”
There were 886 sedation events in 853 unique participants.
The median initial dose of propofol was 2mg/kg. The median
total dose given was 3.6mg/kg. About 80% of patients received
multiple doses.
Findings: 15% had some level of desaturation; 7% of patients
had desaturation below 90%; 1.2% had hypotension. There
were no intubations, but some patients required bag-valve-mask
and jaw thrust.
Most doctors rated their satisfaction above 90. Patient or parent satisfaction was not addressed. In general, doctors didn’t
adjust the dose even if they gave additional medications.
A limitation of the study was that adverse events were selfreported by treating physicians. Although there was a little
more hypoxia than desired, propofol is safe and there were no
reported long-term sequelae. We can probably use higher doses,
but should we?
The patient has uremic frost. This occurs in end stage renal
failure patients not receiving dialysis. The excessive nitrogenous
waste products accumulate in sweat and crystallize, forming skin
deposits. This is an uncommon presentation.
Uremic frost is not life-threatening by itself, but is indicative
of severe failure.
Indications to call your nephrologist colleagues. Remember
the brain, heart and blood.
For the altered uremic patient, remember uremic encephalopathy.
For the dyspneic uremic patient, remember uremic pericardial
effusion.
For the bleeding uremic patient, remember uremic platelet
dysfunction.
Uremic encephalopathy. Presentation may vary from mild
symptoms such as lethargy to a more severe presentation such
as coma or seizures. Why does it happen? It is unclear. There are
some theories that accumulated uremic toxins play a role.
14
How do you treat it? Dialyze the patient. Symptoms will usually resolve within 24 to 48 hours.
Uremic pericardial effusion. Commonly, dyspnea in the end
stage renal failure patient will be due to volume overload, but
also consider other conditions such as pericardial effusion.
Twenty percent of end stage renal failure patients can have pericardial effusion. Shortness of breath or dyspnea is a potential
presenting complaint of pericardial effusion.
You can use them to mark cellulitis. This can be especially
helpful for observation units. Add the date and time. You can
also have patients take a picture with their phone. There won’t
be privacy issues as it is their phone, and they will have the
images with them wherever they go for follow-up.
Other options for marking include edema or track marks in
snakebites. Marking vascular sites in patients can also be helpful.
You can use them to number EKGs.
How do you treat it? If the patient is unstable and we diagnose a pericardial effusion causing diastolic collapse, it is an
indication for emergent pericardiocentesis.
You can use them to label medications, such as ketamine, intubation
medications or drips mixed in the Emergency Department.
If the patient is stable, the patient should go to dialysis.
You can use them to keep track of fluids (such as number of
liters administered) and medications in sick septic patients.
Uremic platelet dysfunction. All end stage renal failure patients
have some degree of platelet dysfunction. This does not correlate with
the serum BUN levels. Some patients may have severe dysfunction.
How do you treat it? DDAVP. How do you give it? You can give
it IV or subcutaneously at a dose of 0.3mcg/kg, or intranasally at a dose of 3 mcg/kg. The intranasal dose is ten times
greater. Dialysis helps.
How does DDAVP work? It helps to release von Willebrand
factor, which makes platelets work better.
How can you dialyze a patient who is bleeding if you need to
administer heparin for dialysis? Heparin-free hemodialysis exists. Discuss the possibility with your specialist.
Packed red blood cell transfusion is controversial. It is thought that
correcting the anemia helps platelet aggregation. The goal is 10g/dL.
Case continued. The patient was started on hemodialysis with
improvement of his mental status and volume status.
You can use them to mark a line 20 feet from the visual acuity chart.
You can use them to mark veins in patients with difficult access. This can be especially helpful with external jugular IVs,
when you have landmarks initially but the veins collapse when
you hit the skin with the needle.
You can mark a limb where you have placed a nerve block so
consultants don’t worry that the patient is not neurovascularly
intact on their assessment. Include a time stamp.
You can label the time and placement of a tourniquet, especially in the prehospital setting.
You can use them to indicate pill bottles that you have counted in a polypharmacy overdose.
You can use them to keep track of patients in a mass casualty incident.
You can use them on the bed sheet to document information
and vital signs.
You can use them to emphasize patient allergies on charts.
You can use them to label your coffee.
The LIN Sessions:
A Million uses for Sharpies in the ED
Michelle Lin MD and Seth Trueger MD
Reasons why Sharpie markers are the best thing to carry at work…
You can use them to leave notes for other providers (i.e.
K=8mEq/L).
Burton C, et al. Can skin marker pens, used preoperatively to
prevent wrong-site surgeries, transfer bacteria? Infect Control
Hosp Epidemiol. 2010 Feb;31(2):192-4. PMID: 20055641.
You can use them to mark the landmarks for cricothyrotomy
on patients with a potentially difficult airway.
They found that the industrial use Sharpie markers stay sterile,
likely due to the alcohol in the ink.
You can use them to mark landmarks when performing lumbar
puncture. This can be useful in maintaining the midline. Draw
a line in the middle of the patient’s back from L1 to L3.
Wipe the marker in between uses.
You can use them to mark fluid pockets identified via ultrasound for paracentesis. If the patient gets up to use the bathroom prior to the procedure or shifts position, you may want
to confirm the site on ultrasound before proceeding with the
procedure, as sometimes the ascites can shift. However, as
long as you aren’t inserting the needle too rapidly, you are
unlikely to puncture the colon.
In summary, Sharpie markers can be used to: mark patients
from an external standpoint for key high-risk procedures, label
things that will reduce patient errors, get the attention of a reader, and label coffee (obviously the most important use).
What else does Trueger carry in his pockets? 2-3 pens. A scalpel. Trauma shears. These can be used for multiple purposes:
cutting clothes/bandages, making splints; getting the nasal cannula out of the way post-intubation; and serving as wrenches or
pliers. Powerful pen-light or mini-LED lights.
15
NOTES
16

The Written Summary of the EM:RAP Monthly Audio Program

Transcription

Similar documents

Murray_The Role of Primary Care in CHF

In-Hospital Cardiac Arrest

Cardiac Arrest Top10 Things to Know

Gabriel Cassalett MD Pediatric Intensivist Clínica Shaio Bogotá

NuQuest Brochure

Resuscitation - Adult - Queensland Ambulance Service

In-Hospital Resuscitation: Implementation of the AutoPulse as part of

8 ways to beautify

Hyperprolactinemia - kusm

Resuscitation Science Symposium

Tinea Amiantacea = السعفة الامينتية