Ventilation Pearls in the Post-Cardiac Arrest Patient
- Some ventilation pearls from the recently released 2010 AHA guidelines include:
- Set the tidal volume to 6-8 ml/kg ideal body weight
- Titrate minute ventilation to achieve a PaCO2 between 40-45 mm Hg or PETCO2 between 35-40 mm Hg
- Reduce the FiO2 to maintain SpO2 > 94%
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In honor of Halloween and candy....
Hyperglycemia (> 140 mg/dl) at the time of admission is an independent risk factor for adverse outcomes and mortality both during the hospital stay and long-term in patients with acute MI. Hyperglycemia is associated with adverse platelet function, thrombolysis, and coagulation. Tight glucose control is recommended to begin as soon as possible after admission in patients with acute MI in order to optimize outcomes.
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Risk Factors for Spinal Epidural Abscesses
Building on Dr. Corwell's pearl from last week concerning Spinal Epidural Abscess, risk factors for Spinal Epidural Abscesses other than IV drug abuse are:
- Diabetes
- ESRD
- Septicemia
- HIV infection
- Malignancy
- Morbid obesity
- Long-term corticosteroid use
- Alcoholism
- Infection at a distal site
- Indwelling catheters
- Spinal surgery
The infection can occur via three routes 1) hematogenous spread 2) Direct Extension from a local infection such as osteoomyelitis, and 3) iatrogenic introduction which is thought to be responsible for 14-22% of the cases. A catheter in the epidural space for more than 2 days has a infection rate of 4.3%.
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Necrotizing Enterocolitis
- NEC is an inflammatory lesion of bowel which can progress to intestinal gangrene, with perforation, and /or peritonitis
- characterized by abdominal distension, feeding difficulties, and GI bleeding
- mainly affects pre-term infants, and most commonly affects distal ileum and proximal colon
- usually presents during the first 2 weeks of life, but may occur up to 3 months of age in infants who who born weighing <1000grams
- classic finding on abdominal XR is pneumatosis intestinalis or air in the bowel wall (pathognomonic) and is present 50-75% of the time
- treat emergently with nasogastric decompression, IVF recussitation, NPO, and IV antibiotics
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When a patient presents to the ED with a recent ingestion of a wild mushroom there are three very specific questions you must ask:
1) Exactly what time did you eat the mushroom?
2) Exactly what time did you begin vomiting/diarrhea/GI Sx in general?
3) Are there are more mushrooms that can be brought to ED for identification?
The reason the first two questions are critically important is it determines the total time of onset of toxicity. As a very general rule of thumb, delayed GI symptoms >6hrs is predictive of a possible lethal ingestion of a cyclopeptide containing mushroom like Amanita Phalloides. Immediate symptoms < 6hrs and even more so if within 2 hrs usually indicates ingestion of a nonlethal mushroom that causes GI distress (many mushrooms like Clitocybe nebularis)
Website with pics of the most poisonous mushrooms:
http://scienceray.com/biology/botany/13-deadliest-mushrooms-on-the-planet/
There is a saying:
"There are old mushroom pickers and wise mushroom pickers but no old and wise mushroom pickers"
Classic Cerebrospinal Fluid Characteristics
- Bacterial Meningitis >> Milky CSF with increased protein, decreased glucose, high WBC's, few RBC's, mildly increased opening pressure, normal % gamma globulin.
- Viral Meningitis >> Cloudy CSF with increased protein, normal glucose, increased WBC's (lymphocyte predominant), no RBC's, normal opening pressure, normal % gamma globulin.
- Herpes Simplex Encephalitis >> Cloudy CSF with increased protein, normal glucose, increased WBC's (lymphocyte predominant), few RBC's, increased opening pressure, normal % gamma globulin.
- Subarachnoid Hemorrhage >> Yellow CSF with increased protein, normal glucose, few WBC's, inumerable RBC's, mildly increased opening pressure, normal % gamma globulin.
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Increasing literature demonstrates ICU delirium is bad. Delirium in mechanically ventilated patients is an independent predictor for long-term cognitive defects (e.g., managing money, following detailed instructions, reading maps, and developing dementia). The cited study found 80% of patients with ICU delirium had cognitive dysfunction at three months, and 70% had residual dysfunction at one year (33% had severe dysfunction).
You must be aggressive to prevent delirium:
- Implement daily assessment tools (e.g., CAM-ICU)
- Daily awakening and spontaneous breathing trials
- Early patient mobilization
- Aggressive pharmacological treatment of delirium
- For more information: www.icudelirium.org
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Magnesium is considered a mainstay of treatment of prolonged QT syndrome leading to torsade de pointe, including those cases caused by drugs. The exact mechanism of action is unknown, though it is thought to stabilize the myocardium. Interestingly, magnesium infusions will not necessarily change the heart rate or QT interval on ECG.
The dose is 2 g IV followed by an infusion (similar to treatment of eclampsia/preeclampsia). The bolus should be given slowly if the patient is relatively stable, but can be pushed over 1 minute in a patient with ongoing torsade that is not responding to electricity.
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Epidural compression syndrome encompasses spinal cord compression, cauda equina syndrome, & conus medullaris syndrome.
Causes include:
- massive midline disc herniation (most commonly), usually at the L4 to L5 level.
- tumor
- epidural abscess
- spinal canal hematoma.
Measurement of a post-void bladder residual volume tests for the presence of urinary retention with overflow incontinence (a common, though late finding) (sensitivity of 90%, specificity of 95%). Large post-void residual volumes (>100 mL) indicate a denervated bladder with resultant overflow incontinence and suggest significant neurologic compromise. The probability of cauda equina syndrome in patients without urinary retention is approximately 1 in 10,000.
Use this in your daily practice!!
The administration of glucocorticoids can minimize ongoing neurologic damage from compression & edema until definitive therapy can be initiated. The optimal initial dose and duration of therapy is controversial, with a recommended dose range of dexamethasone anywhere from 10 to 100 mg intravenously. Consider traditional dosing (dexamethasone 10 mg) for those with minimal neurologic dysfunction, & reserve the higher dose (dexamethasone 100 mg) for patients with profound or rapidly progressive symptoms, such as paraparesis or paraplegia.
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Colic
- excessive, unexplained paroxysms of crying in an otherwise well-nourished normal infant
- lasts >3 hours/day, and occurs >3 days/week...ughh!
- usually occurs at the same time of the day or evening
- usually resistant to most attempts to quell it
- infant may have excess flatus and draw legs up during episodes (but don't change formulas)
- beings in first week of life and ends by 4 months of age
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- A broadly-accepted, standard definition of concussion, also known as mild traumatic brain injury (MTBI), does not exist and is still a work in progress.
- Historically, the diagnosis of concussion has been based upon the presence of three findings: (1) Loss of consciousness (usually for less than 30 seconds), (2) post-traumatic amnesia (usually for less than 24 hours), and (3) a Glascow Coma Scale score of 13 to 15.
- Today, many experts question whether loss of consciousness is inherently associated with concussion, but rather that any change in consciousness, such as that related to amnesia, suffices.
- Patients with the following symptoms should be screened, typically with head CT, for more serious injury: loss of/deteriorating consciousness, persistent headache, dizziness, vomiting, disorientation/confusion, seizure, and unequal pupil size.
- Treatment of concussion consists of monitoring and rest. Symptoms usually spontaneously resolve within 3 weeks, but may persist for up to around 3 months.
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Ketamine for RSI in Hemodynamically Unstable ED Patients
- Recall that ketamine acts as a sympathomimetic resulting in increases in heart rate, blood pressure, and ultimately cardiac output.
- Because of its rapid transport across the blood-brain barrier, its sympathomimetic effects, and lack of significant adverse effects, ketamine is recommended by many organizations as a first line agent for RSI in unstable patients.
- Important contraindications to ketamine include an acute coronary syndrome, aortic dissection, and acute heart failure.
- Take Home Point: Consider using ketamine the next time you need to intubate a hypotensive, critically ill ED patient.
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ECG early repolarization (or sometimes referred to as "benign early repolarization" or BER) is a common finding on ECGs, especially in young patients. It is a common "confounding" pattern when trying to identify STEMI. Here are some pearls that help in distinguishing BER vs. true STEMI. Remember at the outset, though, nothing in medicine is 100%....and that getting old ECGs or getting serial ECGs can be incredibly helpful.
1. BER is ONLY allowed to have STE that is concave upwards. If you ever see STE that is convex upwards (like a tombstone) or horizontal, it MUST be a STEMI.
2. BER should not have ST-segment depression, except maybe in aVR and V1. If there is ST depression in any of the other 10 leads, it is almost definitely a STEMI.
3. If you see STE in the inferior leads, compare the STE in lead II vs. lead III. If the STE in lead III is greater than the STE in lead II, it rules out BER....gotta be STEMI.
4. STE from BER is usually maximal in the mid precordial leads. You CAN have STE in the inferior leads with BER also, but you really shouldn't have STE isolated to the inferior leads. In other words, BER can have (1) STE in the precordial leads alone, or (2) STE in the precordial + inferior leads, but it should never have STE isolated to the inferior leads, and also the STE in the precordial leads should be more prominent than the STE in the inferior leads.
5. BER should usually not have STE > 5 mm. However, I've seen some occasional exceptions when the patient has large voltage QRS complexes.
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Subungual Hematomas:
- Subungual hematomas are collections of blood that form under the nail with injuries to the distal phalanx.
- Those that are < 25% of the nailbed can be drained via trephination and heal well.
- Up to 94% of subungual hematomas that are are associated with a distal phalanx fracture have a nailed laceration. It is commonly taught this hematomas should have the nail removed and the nailbed repaired. However studies from the 1990's have shown that as long as the nail is attached to the nailbed or paronychia and is not displaced; trephination alone can be done to achieve similar outcomes.
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You may already love ondansetron, but consider using it ORALLY followed by PO hydration in children with vomiting.
- Improve ORT success
- Decrease IV placements
- Decrease admission rates
- NOT cause any significant difference in the number of missed serious alternate diagnoses
The size of the study that showed this: N of just under 35,000.
But don't skimp on dosing. The dose is 0.1 - 0.15mg/kg, and you don't reach a max until 8mg. To put this in perspective, a scrawny 115lb (about 53kg) middle school tennis player would get 8mg, an initial dose often reserved for chemo patients in the adult ED.
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Emerging evidence supports using intravenous fat emulsion (Intralipid) therapy for various drug overdoses, particularly those that are lipophilic. Within seconds to minutes of administration, toxic cardiovascular effects are reversed, including return of spontaneous circulation in cardiac arrest patients. Central nervous system effects also tend to improve.
Lipophilic agents for which there has been success include:
- Calcium channel blockers (verapamil, diltiazem, amlodipine)
- Beta blockers
- Bupropion
- Quetiapine
- Lamotrigine
- Sertraline
- TCA's
- Diphenhydramine
Bottom line: Consider intralipid therapy early in the course of a hemodynamically unstable patient with suspected overdose. Give a bolus of 1.5 mL/kg of 20% lipid emulsion over 1-2 minutes.
- When emergently managing stroke, be vigilant about anticipating potential complications and recognizing them with expediency, regardless of whether the patient receives tPA therapy.
- The following are associated with greater risk of developing cerebral edema and/or post-tPA hemorrhage:
--- High NIH Stroke Scale scores.
--- Large areas of infarct.
--- Cerebellar infarcts.
--- Extended time to tPA administration.
--- Previous stroke.
--- Older age.
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Heliox is a mixture of oxygen and helium resulting in a gas less dense than air. In asthma, airway resistance causes turbulent airflow which increases the work of breathing. Heliox reduces airway resistance by increasing laminar airflow.
Benefits:
Better lung mechanics
Improved nebulizer delivery
Few known side-effects/complications
Drawbacks:
Expensive
Contraindicated in hypoxemic patients.
Paucity of large prospective randomized trials.
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Previous pearls have described tips for smart and safe documentation of typical ED complaints such as chest pain. Properly assessing and documenting orthopedic complaints is likewise very important. No evaluation or chart is complete if it does not include include the following 7 components:
The joint above
The joint below
Motor
Sensory
Vascular
Skin
Compartments
The joint above/below is important in cases of shoulder and hip pain actually being radicular pain (from the neck and back respectively). Also, hip pain from trauma may be due to a femur fracture for example.
For motor and sensory evaluation, test the most distal isolated innervation of a particular nerve (L5 - great toe dorsiflexion for example).
Note distal pulses and check ABIs for injuries with potential subtle vascular findings.
Note intact skin especially in cases where the joint will be covered by a splint.
Note "soft" compartments especially in cases of forearm and lower leg fractures.