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Bottom Line: Multiple modalities of intervention may be needed to combat various aspects of salicylate toxicity. These include gastric decontamination, fluid hydration, dextrose admiinistration, aggressive serum alkalinization, establishment of normokalemia and hemodialysis. Intubation and chemical restraint should be avoided if possible.
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A retrospective study looking at use of transdermal Buprenorphine in older trauma patients with rib fractures found a good safety profile (less naloxone use) and less overall opioid use however no change in overall length of stay or mortality. Adding this to your multimodal pain strategy in older patients with rib fractures seems like a reasonable plan.
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A narrative review of literature involving older patients and constipation found:
“Major contributing factors include physical inactivity, sarcopenia, dehydration, inappropriate defecation posture, and polypharmacy, particularly opioids and anticholinergic agents. Importantly, these factors interact through the brain–gut–microbiota axis, contributing not only to gastrointestinal dysfunction but also to systemic outcomes such as frailty, cognitive decline, and increased healthcare burden, thereby supporting a multidimensional disease framework.”
It isn’t as simple as adding a laxative.
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The article outlines how instead of looking at medications as the cause of symptoms, we often add more medications to treat the medication induced symptoms. Here is an example of how we get to polypharmacy in older patients
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Body armor/ bullet resistant vests used by law enforcement are designed to stop penetration by handgun rounds. These rounds have less velocity than rifle rounds. When caring for someone who has been shot while wearing body armor, verify no penetration has occurred and then look for blunt injuries such as rib fractures, liver injuries, pneumothorax, cardiac contusion, vertebral injury, etc. Behind Armor Blunt Trauma (BABT) is the technical term for injuries caused by the transfer of kinetic energy that occurs when these vests are struck.
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This narrative review of the trauma literature looking at chronic pain after trauma found:
- Chronic pain occurs in 30–70% of trauma survivors, with prevalence varying by injury type.
- Key risk factors include female sex, younger age, pre-existing pain, psychological distress, and social disadvantage.
- Validated prediction models are available for musculoskeletal trauma
- Thoracic trauma is under represented in the pain literature, is often underrecognized, and less protocols are available for treatment
- Thoracic pain typically occurs through intercostal nerve damage and persistent pain following thoracic injury
- The authors suggest “A trauma-specific, biopsychosocial approach is key to reducing chronic pain and improving recovery.”
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Ambient Artificial Intelligence based scribes that create visit notes based on the conversation in the room during patient evaluation may save documentation time and reduce total time in the health record but may not perform as well as human scribes in some circumstances, at least for pediatric patient charts.
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PaO2 to FiO2 (P:F) ratios, are often considered the gold standard in critical care for assessing the degree of oxygen-refractory hypoxia in various pathologies, particularly ARDS. P:F does have some limitations, including not accounting for the PEEP, but probably the most limiting is that it requires collecting an ABG, which is invasive and not always feasible or a top priority when resuscitating a critically ill hypoxic patient. On the other hand, SpO2 (pulse ox saturation) is routinely available, and of course the FiO2 should be known, so many have suggested perhaps using an SpO2 to FiO2 (S:F) ratio instead. But how S:F maps to P:F and how well they correlate is not fully known. Chaudhuri et al recently conducted a meta-analysis, published in Critical Care Medicine this month, which reviewed the literature on this.
Bottom Line: Yes, S:F ratios correlate well with P:F ratios, especially when the SpO2 is less than 97%, but you can't just substitute the S:F for P:F, you have to use one of the accepted formulas. See additional info on the website for the actual formula to apply and how a given S:F translates to P:F.
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Sonographic findings suggestive of necrotizing fasciitis include:
- Thickening of the deep fascia
- Diffuse thickening of the overlying fatty tissue
- At least a 4 mm thick fluid layer along the deep fascia
- Dirty Shadow if gas is present
Remember the mnemonic: STAFF (subcutaneous thickening, air, and fascial fluid)
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Bottom line: Routine screening for atrial fibrillation (AF) is not recommended in the emergency department (ED). However, AF is often detected incidentally on continuous ECG monitoring. When identified, clinicians should inform the patient and consider anticoagulation if indicated.
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This German retrospective review of 1500 level one trauma center patients (ICU level or ISS over 9) found obesity was an independent predictor of ARDS, multisystem organ failure, and sepsis but not pneumonia or mortality.
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Multiple past studies have shown that Black and female patients tend to be prescribed fewer opioids than White and male patients. This study looked at the rates of opioid usage post RSI.
They found that while Black patients received opioids at a higher rate, they were given lower doses than white patients. Older patients were less likely to receive opioids post RSI than younger patients. They did not find a difference in rates of opioid usage between genders, but female patients received lower doses of opioids overall.
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Pancreatic injury in pediatric blunt abdominal trauma is rare.
This study was a secondary analysis of the data collected by the Pediatric Emergency Care Applied Research Network (PECARN) in the Intra-abdominal Injury Study Group. Of the children who had blunt abdominal trauma, 6% had intraabdominal injuries and 1% had pancreatitis. A patient was considered as having traumatic pancreatitis if they had 2 of the following: 1) upper abdominal tenderness, 2) serum lipase of amylase > 3 x the upper limit of normal or 3) imaging study positive for pancreatitis.
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Cervical spine injuries (CSI) are uncommon in children, but when present, they are often devastating. However, the application of a cervical collar in children is not benign and adverse effects include neck pain and discomfort and the downward tunnel vision it may create at the hospital leading to unnecessary testing. Recently, the PECARN group published a set of criteria to determine who requires imaging of the cervical spine in the emergency department. A planned subset of this initial study was to collect the impressions of EMS as they pertained to the 9 criteria to determine if these criteria could safely be used by EMS. The patients who were brought in by EMS with the potential for cervical spine injury, who were evaluated by the trauma team and/or had cervical imaging AND had electronic case reports filled out by EMS were included in the final analysis. Only 57% of the patients possible could be included based on the number of electronic case reports that were filled out.
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Summary:
The recent ARISS (Albumin Resuscitation in Septic Shock) trial showed no difference in 90-day mortality or other secondary outcomes, similar to other trials comparing albumin and crystalloid. Notably however, the trial did not meet its predetermined enrollment requirement of patients (in the setting of the COVID-19 pandemic) and had a large portion of its intervention group failing to meet goal serum albumin level.
The Bottom Line:
There remains no evidence-based mortality benefit of albumin over crystalloid in patients with septic shock that do not have additional indications for albumin (such as hepatorenal syndrome). Crystalloid resuscitation remains a staple of appropriate and cost-effective care in septic shock. Albumin can be considered on a case-by-case basis after standard crystalloid resuscitation in this clinical setting.
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This German retrospective study compared the prehospital use of ultrasound by trained paramedics and compared their findings to in-hospital diagnosis and image results. The authors found:
“Diagnostic accuracy, defined as the concordance between prehospital POCUS-based working diagnoses and final in-hospital diagnoses, was particularly strong for lung ultrasound (pneumothorax, pulmonary edema, pneumonia and pleural effusion; sensitivity 91.7%, specificity 100%) and eFAST (sensitivity 100%, specificity 96.5%), while for the abdominal ultrasound examinations, the specificity was 70% and sensitivity was 71.43%.”
This study sets the stage for future prospective work looking at prehospital US use by paramedics.
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What elements of the history are most helpful for diagnosing a concussion?
An estimated 1.1 million to 1.9 million pediatric concussions occur annually in the US.
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BOTTOM LINE:
- Use of VL and cuffed ETTs are appropriate for all ages
- Hyperangulated blades, LMAs and scopes should be available for rescue
- Apneic oxygenation is useful in neonates.
A 2024 meta analysis from the European Society of Anaesthesiology and Intensive Care and British Journal of Anaesthesia worked to develop joint guidelines for best practices for intubation of neonates and infants.
While this guide is focused primarily on anesthesia and operative care, several of the recommendations have practical application to the EM and ICU as well.
They focused on general guidance including ensuring appropriate anesthesia and analgesia during intubation. But also discussed that videolaryngoscopy with standard blades is the most appropriate first line for all intubations in this age group. It allows for appropriate visualization either directly or by video and for learners allows instructors to observe as well.
When there are difficulties with intubation, hyperangulated blades have very high success rates, but LMA and video assisted intubation with a fiberoptic scope are also appropriate next steps for securing an airway.
When intubating, uncuffed endotracheal tubes are acceptable in all infants though cuffed are also safe in infants over 3kg in weight.
Finally, while apneic oxygenation is regularly used in adults, it is also recommended in the neonatal period to avoid hypoxia.
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TenCRAOS was a phase 3 randomized, multi-center, double blind, double dummy, placebo-controlled trial in 78 patients that showed no significant difference in visual outcomes at 30 days for IV tenecteplase 0.25 mg/kg compared to aspirin 300 mg alone within 4.5 hours of central retinal artery occlusion (CRAO) symptom onset. Tenecteplase was associated with more serious adverse events, one of which was a fatal intracerebral hemorrhage.
Bottom line: Although tenecteplase has theoretical advantages in CRAO, the results of this trial do not support routine use.
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This systematic literature review looking at gender differences in trauma care reveals:
- Women were older with more low-energy trauma than men.
- Women were more likely to suffer from pelvic and spinal cord injuries.
- Women were more likely to be under-triaged and under-treated.
- Sex/gender-based differences in mortality were inconsistent across studies.
- Adjusted mortality appeared similar between women and men