After three failed attempts, the FDA finally granted approval for Merck's non-depolarizing neuromuscular blocker reversal agent sugammadex (Bridion). Though the product has been used in Europe and Asia for several years, hypersensitivity concerns led to the delayed approval in the U.S.

Important points

1. Reverses rocuronium, vecuronium, and to a lesser degree, pancuronium
2. Full reversal obtained about 3 minutes after administration
3. Eliminated entirely by the kidneys in about 8 hours (6 times longer in patients with CrCl < 30 mL/min)
4. Dosing is generally 2-4 mg/kg. Total body weight should be used in obese patients

Application to Clinical Practice

1. Potential for use in situations where a neuro exam is needed shortly after intubation (eg, status epilepticus, ICH)
2. The risk of serious hypersensitivity appears to be < 1% in published literature
3. Cost will most assuredly be high
4. Long duration in patients with reduced kidney function means further attempts to re-paralyze with roc, vec, or pancuronium may be unsuccessful

The EM PharmD blog discusses sugammadex's approval in more detail.

Show References

Many providers may not be familiar with the "J-Tip" (National Medical Products Inc, Irvine, CA) which is a needle-free jet injection system that uses air to push buffered lidocaine into the skin. In theory, it provides quick local anesthesia without a needle, making it an ideal tool to reduce the pain of pediatric venipuncture. Maybe you will consider giving it a try?...but what is the data for it?

Show References

Attachments

• 1601020306_jtip_works.jpg (24 Kb)

In many countries, alcohol is commonly drunk for special occasions, such as New Year’s.  What can be the consequences of drinking too much?

As noted in an article on the validation of the Dutch version of the brief young adult alcohol consequences questionnaire, the most common consequences were:

1. Had a hangover: 74.3%
2. Had less energy or felt tired because of my drinking: 63.9%
3. While drinking, I have said or done embarrassing things: 38.0%
4. Felt very sick to my stomach or thrown up after drinking: 34.1%
5. Ended up drinking on nights when I planned not to drink: 29.2%
6. Not gone to work or missed classes because of drinking: 28.0%
7. Not been able to remember large stretches of time: 26.8%
8. Taken foolish risks: 24.7%
9. Quality of my work or school work has suffered: 21.7%
10. When drinking, I have done impulsive things I regretted later: 21.4%

According to the Alcohol Hangover Research Group Consensus Statement on Best Practice in Alcohol Hangover Research, items 1, 2, 4, 6 and 9 are or may be related to hangovers.

Have an enjoyable, but safe New Year.

Show References

Acute Chest Syndrome

• Acute chest syndrome (ACS) accounts for the most common cause of ICU admission and the most common cause of death in sickle cell patients.
• Important pearls for ACS include:
  • Chlamydophila pneumonia is the most common bacterial cause of ACS in adults, whereas Mycoplasma pneumonia is the most common bacterial cause in children.
  • CXR abnormalities may be absent early in disease.
  • Children are more likely to have middle lobe disease, in contrast to adults who often have lower lobe involvement.
  • Acute RV failure is a well recognized complication of ACS - use ultrasound to evaluate the RV and be careful with fluids.

Show References

Question

79 year-old male with headaches, ataxia, falls, and difficulty urinating. What's the diagnosis?

Show Answer

Show References

Protracted Recovery from Concussion

Age and sex may influence concussion recovery time frame

Methods: 266 adolescent athletes presenting to a sports medicine concussion clinic

Female athletes had a longer recovery course (P=0.002) and required more treatment interventions (p<0.001).

Female athletes were more likely to require academic accommodations (p<0.001), vestibular therapy (P<0.001) and medications (P<0.001).

Be aware that not all concussion patient subgroups with concussions recover in the same manner. Further study is needed to support whether female adolescent athletes require unique management and treatment guidelines.

Show References

HSV infection of the CNS is one of few treatable viral diseases. HSV encephalitis of older children and adults is almost always caused by herpes simplex virus type 1 (HSV-1), and in individuals older than 20, is due to HSV reactivation.

Temporal lobe localization is characteristic for HSV encephalitis in individuals older than 3 months, and is responsible for its characteristic presentation, namely bizarre behavior and expressive aphasia.

CSF analysis will usually reveal an elevated protein level, and a lymphocytic cellular predominance.

CSF protein concentration is a function of disease duration, and will continue to rise even with administration of treatment (acyclovir) and may remain elevated after the completion of therapy.

5% of CSF samples will be totally normal, and the diagnosis will only be revealed with positive PCR detection of viral DNA in the CSF, which is the gold standard for diagnosis.

The sensitivity of MRI is similar to CSF analysis, with 5% of patients with HSV encephalitis having a normal MRI on presentation, and subsequently developing abnormalities.

Of note, HSV-2 tends to cause aseptic meningitis rather than encephalitis in adults, and has a benign course.

Bottom Line? Keep a high index of suspicion for HSV encephalitis, and treat the patient empirically despite a normal CSF/MRI pending PCR results.

Show References

The EuroTherm3235 Trial was a randomized, multi-center trial to study hypothermia (32-35^oC) in severe, traumatic brain injury¹:

• Hypothermia was compared with hyperosmolar therapies (hypertonic saline and mannitol) as "Stage 2" management.
• While hypothermia did successfully reduce ICP, functional outcomes (as measured in Extended Glasgow Outcome Score [GCS-E]) trended towards harm at six months (though not significantly different).
• Take-home: The study design has significant flaws, but the lack of clear benefit of hypothermia is consistent with previous studies² and suggests that fever prevention or controlled normothermia (36^oC) may be ideal for severe TBI patients, but needs further study.

Show References

Quick pearl for those that are trying to complete their holiday shopping.

Mulder's sign is not a sign that there is an extra-terrestial in your ED, But rather a sign that your patient is suffering from a Morton's Neuroma (see pearl from 2012)

Patients will often complain of pain in 3rd and 4th intermetatarsal space and if you can reproduce the pain by compressing the metatarsal heads together then you have a Positive Mulder's sign. Check out the original pearl at https://umem.org/educational_pearls/1684/

Show References

Synthetic cathinones, known as bath salts, are a frequently used street drug in the United States.  They have been discussed in a number of previous pearls.  But from where did cathinone originate?

Khat (Catha edulis) is flowing plant native to the Arabian Peninsula and the Horn of Africa. It contains the monoamine alkaloid cathinone, which is an amphetamine-like stimulant that also causes euphoria. Historically, khat has been chewed for thousands of years and predates the use of coffee.  Khat chewing is particularly popular in Yemen.

Khat contains many different compounds, which cause a number of different effects. Many of these effects are considered harmful to health. Khat chewing primarily impacts the central nervous system and the gastrointestinal system. However, it also has effects on cardiovascular, respiratory, endocrine, and genitourinary systems.  In addition to the amphetamine like central nervous effects, other toxic effects include elevated blood pressure, tachycardia, insomnia, anorexia, constipation and general malaise.

Next time you see a patient with confusion and hallucinations from Yemen, Ethiopia, Somalia and other countries around the Horn of Africa, consider Khat in your differential.

Show References

Question

A patient arrives in acute respiratory distress with left sided chest pain. Ultrasound of the left anterior chest is shown; what's the diagnosis and name one false positive?

Show Answer

Show References

Question

Show Answer

Show References

Parental Knowledge of pediatric concussion

Sample: Parents of children brought to pediatric hospital or outpatient clinics for evaluation of orthopedic injuries.

Participants scored an average of 18.4 (0-25) on knowledge and 63.1 (15-75) on Attitudes toward concussions.

Safest attitudes were seen in white females. Knowledge increased with income and education levels.

Parents from low income or education levels may benefit from additional education in the ED prior to discharge in addition to providing paper information which may not be read or understood.

Show References

The American Academy of Clinical Toxicology's Lipid Emulsion workgroup has published its first of 4 systematic reviews on the use of lipid emulsion in toxicology, this one on lipid's effect on laboratory analyses. [1] As expected, administering a fat bolus can significantly alter labs drawn subsequently.

The key point: If you are considering lipid for overdose, draw labs prior to giving it.

Which labs are affected? Most. Here's a helpful mnemonic courtesy of Dr. Kyle DeWitt.

• B - Blood Gas
• L - Liver transaminases
• E - Electrolytes
• A - Analgesics (acetaminophen, salicylates)
• C - Coags
• H - H/H, platelets

Also remember to give lipid in its own line. It isn't compatable with most resuscitation drugs. [2]

Show References

• The NIH Stroke Scale (NIHSS) is a widely used scale in assessing neurological deficits in stroke patients.
• It is a useful communication tool and is accurate in predicting clinical outcomes.
• However, it has been critiqued for its complexity and potential poor interrater reliability of certain items within the scale.
• Prior studies have suggested modifying or shortening the scale to 11, 8 or 5 items for use in stroke clinical trials or the prehospital setting.^1,2,3

A recent study compared the original NIHSS with the shortened 11, 8, and 5 item versions.⁴

• They found the original NIHSS has higher discriminatory value and responsiveness to change as well as improved ability to predict clinical outcomes than shortened versions.

Bottom Line: The original 15-item NIHSS should still be used to evaluate patients’ stroke severity.

The reliability of the NIHSS has been found to improve with personal and videotaped training.

Show References

• What type of fluid we use in critical care resuscitation has been hotly debated for some time
• The most recent battles have been played out between NS and plasmalyte or buffered solutions
• There has been some evidence that high chloride solutions can lead to renal injury requiring renal replacement therapy (RRT)
• Does a buffered crystalloid reduce renal complications compared with normal saline in patients admitted to the ICU?
• The SPLIT Trial (Saline vs Plasma-Lyte) from New Zealand ICU's adds more to our knowledge about this topic while enrolling over 2,000 patients
• Summary:

1. Primary outcome was a rise in creatinine
2. There was no difference in the primary outcome or incidence of AKI
3. There was no difference in use of RRT or mortality
4. Suggesting that is doesnt make too much of a difference

• There were some limitations: 90% of patients were given fluid before enrollment that was buffered crystalloid and patients were only given around 2 liters on average of fluid in the ICU

The Bottom Line: This was a nicely designed study to evaluate the safety of both fluids. It does suggest that either fluid type is for the most part OK. But in patients requiring hefty fluid boluses, we should be cautious in what type of fluid we choose.

Show References

Question

Show Answer

Show References

Tramadol has a reputation for being a safe, non-opioid alternative to opioids. Nothing could be further from the truth. Several blogs have published about the dangers of tramadol:

• Tramadol: When to Avoid It from ALiEM blog
• Three Reasons Not to Prescribe Tramadol from EM PharmD blog
• Hypoglycemia: Another Adverse Effect Associated with Tramadol from Poison Review blog

But what about seizure risk? Previous studies have been unable to confirm an increased seizure risk with therapeutic doses of tramadol (Seizure Risk Associated with Tramadol Use from EM PharmD blog). However, a new study refutes that premise.

22% of first-seizure patients had recent tramadol use!

1. Mean total tramadol dose in last 24 hours (reported): 140 mg
2. Duration of tramadol use less than 10 days: 84.5%
3. Seizure within 6 hours of tramadol consumption: 74%

This was a retrospecitve study without laboratory confirmation of tramadol intake. Nevertheless, it behooves us not to think of tramadol as a safer alternative to opioids. It is an opioid after all, and it comes with significant adverse effects.

Show References

Carbon monoxide (CO) is a colorless, odorless, tasteless toxic gas produced by incomplete combustion in fuel-burning devices and is a leading cause of poisoning morbidity and mortality.

Symptoms can be easily misinterpreted (e.g., headache, nausea, dizziness, or confusion) thus victims may not realize they are being poisoned.

CO detectors use an audible alarm and are effective in alerting potential victims of presence of CO. Some versions offer a digital readout of the CO concentration. Detectors are not a simple alarm level (as in smoke detectors) but are a concentration-time function.

In the UL 2034 Standard, Underwriters Laboratories specifies response times for CO alarms:

• 70 ppm sounds alarm within 60-240 minutes
• 150 ppm sounds alarm within 10-50 minutes.
• 400 ppm: sounds alarm within 4-15 minutes.

Current Occupational Safety and Health Administration permissible exposure limit for CO is 50 parts per million as an 8-hour time-weighted average concentration.

CO detectors have a limited lifespan of up to 7 years.

Forty percent of residential detectors studied failed to alarm in hazardous concentrations, despite outward indications that they were operating as intended.

CO detectors 10 years and older had the highest failure rates.

Show References