Gooble, gooble,… gulp, some food for thought on the eve of Thanksgiving.
The development of artificial intelligence (AI) in emergency medicine is well under way. The schematic below and accompanying reference presents the anticipated stages in the process of AI development, including important features, considerations, and challenges as we move towards increased integration of AI in our practice of EM.
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It’s the age-old question. We’ve read studies comparing propofol vs. etomidate, ketofol vs. etomidate, and now a meta-analysis about ketamine vs. etomidate. Etomidate is the staple induction agent for RSI, mostly used by Emergency Medicine, and to a degree in the Intensive Care Unit. However, the question about adrenal suppression was initiated in the early 2000s and researchers have been looking for other alternatives. This meta analysis attempted to look for another answer.
Settings: A meta-analysis of randomized controlled trials
Participants: 2384 patients who needed emergent intubation were included.
Outcome measurement: Peri-intubation instability
Study Results:
Compared with etomidate, ketamine was associated with higher risk of hemodynamic instability and moderate certainty (RR 1.29, 95% CI 1.07-1.57).
Ketamine was associated with lower risk of adrenal suppression, again, with moderate uncertainty (RR 0.54, 95% CI 0.45-0.66).
Ketamine was not associated with differences and risk of first successful intubation nor mortality.
Discussion:
Most studies were single center and involved small-moderate sample size, ranging from 20 patients to 700 patients.
For adrenal suppression, there were only 3 studies and a total of 1280 patients, thus, the results are still not definitive.
For an academic exercise, the Number Needed to Harm for both hemodynamic instability and adrenal suppression are calculated here.
Number Needed to Harm for hemodynamic instability: 25.
Number needed to harm for adrendal suppression: 11.
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One of the many siginificant complications of cancers we encounter in the ED is cord compression. Here are pearls from a recently published systematic review focused on metastasis-associated spinal cord compression:
- Spinal cord metastatic lesions affect 5% to 10% of the oncology patients in the United States
- Thoracic spine is most commonly involved (70%), followed by lumbosacral spine, then cervical spine
- Primary sources of spinal metastases are the lung (31%), breast (24%), gastrointestinal tract (9%), prostate (8%), melanoma (4%), kidney (1%), lymphoma (6%), and unknown origin (2%)
- Patients present with pain, motor/sensory deficits, and/or even autonomic dysfunction and neurogenic shock
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It is important for trauma and emergency care providers to understand what our patients experience prior to arrival in our clean, safe, and structured emergency department. It is also vitally important that we are involved in training and education in the pre-hospital environment. A group in the United Kingdom is challenging the age old “wisdom” that post-motor vehicle crash extrication should be slow, methodical, and work to have absolutely no movement in the spinal canal. Spinal immobilization and slow extrication instead of rapid resuscitation appears to be bad for patients. Based on several of their ground breaking papers they have published a 14 point recommendation of patient extrication post motor vehicle collision. Here are two important tenets they propose. For an in-depth discussion check out November 14, 2024 / CPD, Podcasts, Roadside to Resus.
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Ankle sprains are frequently lateral.
They occur less frequently to the medial or “high” ankle.
High ankle sprains without fracture occur in 5-6% of ankle injuries presenting to the ED
Rates of injury are much higher in college and professional hockey and football players
The tibiofibular syndesmosis is primarily injured in high ankle sprains
Mechanism: Typically, external rotation or eversion on a dorsiflexed ankle
Example: When a player’s leg is forcefully rotated while foot is planted
Hx: anterior lateral ankle pain. Frequently significant pain with weight bearing.
PE: local tenderness over the syndesmosis ligaments
Two specialized tests may aid in the diagnosis
- The Squeeze test – This test attempts to reproduce the pain from the tear/instability. Have patient sitting on edge of bed with leg hanging off end to gravity. Examiner squeezes mid calf to create medial lateral compression. Reproduced pain is a positive test. Low sensitivity high specificity.
https://wikism.org/Squeeze_Test#/media/File:Squeeze_test_example.jpg
2. Dorsiflexion-external rotation test – This test attempts to reproduce the forces commonly involved in the original injury. Positive test is reproduction of pain. Position patient similar to above test. Grasp the upper calf with one hand while the other hand grasps the midfoot and places the foot in dorsiflexion and external rotation.
https://www.dralexjimenez.com/wp-content/uploads/2017/07/external-rotation-test-1.png
The authors looked at 51 patients intubated with both anterior and posterior cervical collar in place and measured the degree of movement within the spine during intubation. They repeated this process in 51 additional patients with just the posterior portion of the collar in place. They found there was one degree of difference in movement between the two groups. This adds evidence that removing the anterior portion of the collar is safe when intubating trauma patients.
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Achilles tendon injuries are commonly encountered in the emergency department. While MRIs are often unavailable, POCUS offers a quick and effective alternative for evaluating such injuries. In one review, the sensitivity of ultrasound for detecting complete Achilles tendon ruptures was 94.8%.
For the POCUS evaluation of the Achilles tendon:
- Place the patient in a prone position with their foot relaxed.
-Begin distally at the tendon’s insertion on the calcaneus and scan proximally, keeping the probe marker oriented toward the patient’s head.
-Next, obtain a transverse view by rotating the probe marker toward the patient’s right side.
-You can even do a sonographic Thompson’s Test!
Findings:
Complete Rupture: Displays as a full disruption of the tendon fibers.
Partial Tear: Shows intact tendon tissue with surrounding edema.
Tendinitis: Appears as a thickened tendon with increased vascularity on color Doppler imaging.
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This retrospective study illustrates that the use of CT scanning to identify injury in gun shot wounds to the abdomen is not sensitive or specific enough to obviate the need for laparotomy. “Admission hypotension, abdominal pain and/or peritonitis, evisceration, and a transabdominal trajectory were considered clear indications for laparotomy.” If there is clear indication to go to the OR, stopping in CT does not add any benefit.
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This article was a review of randomized control trials using intranasal (IN) fentanyl. There were 8 studies included that showed IN fentanyl was superior to controlling pain compared to other pain medications at the 15-20 minute mark, but not at the 30 and 60 minute marks. There were less reports of nausea and vomiting with IN fentanyl, but no difference in dizziness or hallucinations compared to the other medications included in the various trials (ie morphine, ketamine, po narcotics, ect)
The bioavailability of IN fentanyl ranges from 71-89% with effects noted in 2 minutes with maximal concentrations noted at 7 minutes. The half life is approximately 60 minutes.
Bottom line: Consider IN fentanyl for quick acute pain management in the pediatric patient.
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An out-of-hospital, randomized, placebo-controlled, blinded, parallel group study was conducted in adult patients under the care of the city fire-based emergency medical services and the local level one trauma center. Adult male patients experiencing moderate to severe pain due to traumatic injuries received either 50mg of intranasal ketamine or placebo in addition to fentanyl after randomization in the field by the paramedic (a novel approach). The primary outcome was reduction of pain by 2 points 30 minutes after study drug administration.
199 patients were randomized with 107 receiving ketamine and 92 with placebo. Patients were young (30-40), and had a median weight of 83 kg. Pretreatment pain scores were 10/10 and patients presented to the ED 14 minutes after receiving study medication. The most common injuries were falls, MVC, and GSW. Half of the patients received IV fentanyl but others had IM or IN routes.
Ketamine receipt did not lead to a 2 point reduction in pain scores (36% vs 44.7% p = 0.22). There was no difference in pain at 3 hours, additional medications received, or total amount of analgesia received. Notably, there were no differences in adverse events.
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Administration of prehospital TXA was found to improve 28 day mortality and decrease the amount of blood required to be transfused without any increased risk of thromboembolism or seizure. Two grams of TXA was superior to one gram and no TXA.
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In this small retrospective study comparing outcomes before and after a prehospital blood administration protocol for penetrating trauma was initiated, the authors found improved survival in those receiving prehospital blood despite a five minute longer on scene time in those receiving blood. Also note TXA was part of the blood protocol but not the control group.
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Trigger finger/thumb
Occurs from mechanical impingement
-Stenosing tenosynovitis
Much more common in patients with diabetes
Causes clicking, catching, locking and pain
Occurs at the A1 pulley
Flexor tendon “catches” as it attempts to glide through a stenotic flexor tendon sheath
Initially, patient's report painless catching or locking of the affected digit during flexion
During finger flexion and extension, pain is caused by inflamed tendon passing through a relatively constricted tendon sheath
Occurs most often in the ring and middle digits
May improve over the course of the day
Diagnoses with active triggering (with digit flexion and extension) and tenderness to palpation at the first annular pulley (A1) which overlies the first MCP joint
-Ask patient to place hand on table face up and gradually fully flex and extend the fingers
May note a palpable nodule of the flexor tendon
Treatment: Activity modification, NSAIDs and splinting (3-6 weeks)
Corticosteroid injection is very effective
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Neonates are more prone to seizures than children of other ages. Ultimately, a cause of seizures is more likely to be identified in the newborn. Neonatal seizures are subtle and careful attention to repetitive motions of the face, arms or legs should be considered worrisome for seizure. Generalized tonic clonic seizures are rare in this patient population.
Common Causes:
Hypoxic ischemic encephalopathy (most common), infection, stroke, non-accidental trauma, intracranial hemorrhage (including from vitamin K deficiency), metabolic disorders, and structural abnormalities.
Guidelines for Treatment:
Phenobarbital should be used as first line, unless there is concern for channelopathy based on family history. Some literature does suggest possible benefits of a benzodiazepine in conjunction with phenobarbital for seizure cessation, but care should be given due to high risk for respiratory suppression in neonates.
For seizures that are unresponsive to first line treatment, consider phenytoin, levetiracetam, midazolam, or lidocaine.
A trial of pyridoxine can be attempted in patients who are unresponsive to initial measures
Evaluation:
Neonatal seizures require a full evaluation, including labs, head imaging (MRI preferred), low threshold for LP post imaging, concern for trauma
Disposition:
Neonates presenting with seizures require admission to the hospital for ongoing evaluation and monitoring.
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In out of hospital cardiac arrest (OHCA), does it matter if you choose an intraosseous (IO) vs intravenous (IV) approach to getting access and giving meds?
No, according to a recent study by Couper et al, just published in NEJM. No significant difference in any clinically meaningful outcome including survival, neurologically intact discharge, etc. Technically the IV group had slightly higher rates of ROSC, which just met statistical significance, and to be fair that group did trend very slightly towards better outcomes in some categories, but really well within the range expected by statistical noise.
Interestingly, the median time from EMS arrival to access being established was the same in both groups (12 minutes), which I think raises some face validity questions. Furthermore, of course, previous trials have raised questions as to whether ACLS meds even work or impact outcomes anyways, so naturally if they don't, the method by which they are given isn't likely to matter either.
Bottom Line: This large, well conducted trial continues to support the notion that either an IV-focused, or IO-focused approach to access and medication delivery in OHCA is reasonable. You and your prehospital colleagues can likely continue to make this decision based on personal comfort, local protocols, and patient/case circumstances. At the very least, this continues to support the notion that if an IV is proving challenging, pursuing an IO instead is a very appropriate thing to do.
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If significant orbital edema prevents visual assessment of the pupillary light reflex, ocular ultrasound can be a useful alternative.
- Set up for a standard ocular POCUS exam.
- Place the linear probe transversely over the lower portion of the eye and tilt it upward to visualize the iris and pupil.
- Shine a light over the affected eye to observe the direct light reflex.
- For consensual reflex, shine the light over the opposite eye.
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This study used the New York State hospital discharge database to look for factors associated with being the victim of repeat gun violence.
Unanswered questions include: is it similar in other areas, what interventions at the patient level could prevent this, what other patient level factors (substance use, etc) are involved, however, this is a good start in looking at this preventable disease.
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Recent studies continue to highlight that Black, Native American, female, uninsured and Medicaid patients receive disproportionately more substance use screening when they are trauma patients. The authors of this paper point out that this inappropriate application of screening leads to missed opportunities.
“Screening patients for drug and alcohol use following injury is an evidence-based practice that can trigger wraparound care, such as brief substance use interventions, to prevent reinjury. Adolescents who consume alcohol but are not screened for alcohol use have 2- to 3- fold greater likelihood of reinjury compared with those who were screened and received a brief intervention.”
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By Bobbi-Jo Lowie, MD
Assistant Professor
Emergency Medicine
University of Maryland School of Medicine
Since April of 2024 there have been 36 confirmed cases of avian influenza A across the United States. Avian influenza, primarily caused by influenza viruses that infect birds, can pose significant health risks to both animals and humans. The most notable strains include H5N1 and H7N9, with H5N1 being particularly alarming due to its high mortality rate among infected humans. The virus primarily spreads from birds to humans through direct contact with infected birds, their droppings, or contaminated environments. Although there have been recorded cases of human-to-human transmission, this usually occurs only in close-contact situations.
In humans, avian influenza can present with symptoms ranging from mild respiratory illness to severe pneumonia. Patients may experience fever, cough, sore throat, muscle aches, and in severe cases, gastrointestinal symptoms. Those that have more moderate or severe illness may develop shortness of breath, altered mental status, or seizures. Complications include acute respiratory failure, pulmonary hemorrhage among others, with respiratory failure being the most common cause of death in this patient population.
Diagnosing avian influenza involves a combination of clinical presentation, travel history, and exposure to birds and confirmation through PCR testing of upper respiratory tract samples like a nasopharyngeal swab.
Treatment for avian influenza focuses on antiviral medications such as oseltamivir which is most effective when administered early in the course of the illness but still administered after 48 hours of illness. Supportive care is essential for managing severe cases, especially those that progress to acute respiratory distress syndrome.
Hypertension in the ED comes in two varieties: emergency and asymptomatic (not urgency!). From this position statement: “Hypertensive emergency involves acute target-organ damage and should be treated swiftly, usually with intravenous antihypertensive medications, in a closely monitored setting.”
Conversely, asymptomatic does not require urgent, aggressive management. “Recent observational studies have suggested potential harms associated with treating asymptomatic elevated inpatient BP, which brings current practice into question.”
Without target organ involvement, we do not need to be initiating IV medications or trying to treat the numbers