Search
Negative-pressure pulmonary edema (NPPE) is a well-documented entity that occurs after a patient makes strong inspiratory effort against a blocked airway. The negative pressure causes hydrostatic edema that can be life-threatening if not recognized, but if treated quickly and appropriately, usually resolves after 24-48 hours. These patients may have any type of airway obstruction, whether due to edema secondary to infection or allergy, laryngospasm, or traumatic disruption of the airway, such as in attempted hangings.
Management:
1. Alleviate or bypass the airway obstruction.
· Usually via intubation; may require a surgical airway
· If obstruction in an intubated patient is due to biting on tube or dyssynchrony, add bite-block (if not already in place), sedation, and even paralysis if needed.
2. Provide positive pressure ventilation and oxygen supplementation.
3. Use low tidal volume ventilation.
4. In severe hypoxemia without shock, add a diuretic agent and consider additional measures such as proning and even ECMO if the hypoxemia is refractory to standard therapy.
Show Additional Information
Show References
Viscosupplementation
Hyaluronic acid (HA) is a high-molecular weight polysaccharide
A major component of synovial fluid and of cartilage
Major role of HA is as a lubricant, shock absorption, antinociceptive effect
Used in veterinary medicine for decades
Multiple brands exist with differences based on the molecular weight and how they are produced
Use supported by the Cochrane database (2007, 2014) for knee OA
Post injection strength gains are due to pain relief
May have a role for those who cannot receive steroid injections
Inject in similar manner to intra articular steroids
Caution in those with known allergy to poultry /eggs
Risks: Local reaction (likely from preservative), injection site pain, infection, bleeding.
Radiographs studies can be valuable in poisoning diagnosis, management, and prognosis. Radiographic imaging should be utilized for the following toxins:
- Iron (gastrointestinal)
- Mercury (gastrointestinal, intravenous or subcutaneous)
- Lead (bullets intraarticular, gastrointestinal foreign bodies, lead lines)
- Zinc phosphide (gastrointestinal)
Container toxins - Body packers
- Drug packets and vials
Sustained Released preparations
- Potassium Chloride
Show Additional Information
Show References
There have been reports of “intoxication” or adverse effects among first responders and law enforcement due to exposure to a “powder” suspected to be fentanyl or its analog.
This has led to a significant concern among first responders and law enforcement when investigating or handling “powder” at the scene of overdose or drug enforcement related raids. (http://www.foxnews.com/health/2017/08/15/police-department-gets-hazmat-like-protective-gear-for-overdose-calls.html)
American College of Medical Toxicology and American Association of Clinical Toxicology recently published a position statement to help clarify the potential health risk associated with exposure to fentanyl and its analogs.
- Opioid toxicity is unlikely from incidental dermal exposure.
- Nitrile gloves provide sufficient protection against dermal exposure.
- N95 respirator provide sufficient protection against aerosolize fentanyl/opioids.
- Naloxone should be administered for patients with objective signs of opioid toxicity - hypoventilation and CNS depression – not for vague or subjective symptoms.
With the recent destruction by Hurricane Harvey and the impending impact of Hurricane Irma, it is important to recognize the historical death toll from natural disasters. While the list can vary, here is a top ten list from the library of the National Oceanic and Atmospheric Administration:
| Rank | Event | Location | Date | Death Toll (Estimate) |
| 1 | 1931 Yellow River flood | Yellow River, China | Summer 1931 | 850,000-4,000,000 |
| 2 | 1887 Yellow River flood | Yellow River, China | September-October 1887 | 900,000-2,000,000 |
| 3 | 1970 Bhola cyclone | Ganges Delta, East Pakistan | November 13, 1970 | 500,000- 1,000,000 |
| 4 | 1201 Earthquake | Eastern Mediterranean | 1201 | 1,000,000 |
| 5 | 1938 Yellow River flood | Yellow River, China | June 9th, 1938 | 500,000 - 900,000 |
| 6 | Shaanxi Earthquake | Shaanxi Province, China | January 23, 1556 | 830,000 |
| 7 | 2004 Indian Ocean earthquake/tsunami | Indian Ocean | December 26, 2004 | 225,000-275,000 |
| 8 | 1881 Haiphong Cyclone | Haiphong, Vietnam | 1881 | 300,000 |
| 9 | 1642 Kaifeng Flood | Kaifeng, Henan Province, China | 1642 | 300,000 |
| 10 | Tangshan Earthquake | Tangshan, China | July 28, 1976 | 242,000* |
* Official Government figure. Estimated death toll as high as 655,000.
Show References
Alpha-blockers (tamsulosin, alfuzosin, doxazosin, and terazosin) are antagonists of alpha1A-adrenoreceptors, which results in the relaxation of ureteral smooth muscle. Current evidence suggests alpha-blockers may be useful when ureteral stones are 5-10 mm; however, there is no evidence to support the use of alpha-blockers with stones <5 mm. Patients with ureteral stones >10 mm were excluded from studies utilizing these medications.
The size of most ureteral stones will be unknown due to the lack of need for imaging able to measure stone size. Given that the median ureteral stone size is <5 mm, most patients will not benefit from the use of an alpha-blocker.
Also, keep in mind that the data for adverse events with alpha-blockers used for ureteral stones is limited and that these medications have a risk of hypotension.
Show Additional Information
Show References
Background:
There is an increased incidence of venous thromboembolic events (VTE) in pediatrics due to improved diagnosis and survival of children with VTE.
The mortality rate is estimated at 2%.
The most common etiologies vary by age - Central venous catheters in neonates and infants, and inherited thrombophilia in children and adolescents.
Learning Points:
-
With neonates and infants, carefully assess medical history from neonatal period. Umbilical lines? PICC? Broviac? History of these is likely to be the cause.
-
In children and adolescents, unprovoked VTE is most likely due to inherited thrombophilia, and can be DVT, PE, Portal venous thrombus, etc.
-
Antithrombin deficiency: The first discovered inherited thrombophilia. The result is a lack of inhibition of coagulation factors – IIa, IXa, Xa, XIIa.
-
Protein C or/and S deficiency: The result is lack of inhibition of activated Factor V.
-
Factor V Leiden: Most common inherited thrombophilic defect. Resultant activated Factor V is resistant to normal Protein C and S activity.
-
Prothrombin Mutation: Second most common inherited thrombophilia. The result is increased levels of prothrombin, which increases the half-life of factor Va.
-
-
Initial treatment of clinically significant VTE can start with enoxaparin (1-1.5 mg/kg q12-24h, while checking Anti-Xa levels 4 hours after administration for therapeutic dosing.)
Pearl: Testing for thrombophilia is not always appropriate when diagnosing pediatric patients with their first VTE, but in children and adolescents with first diagnosed, unprovoked VTE, it is worthwhile to send off the initial hypercoaguability work up as this can affect the duration of treatment and need for testing or evaluation. Enoxaparin is a recommended medication to start therapeutic treatment of VTE, even in pediatric patients.
Show References
- Most poisonous substance known to man
- LD50 oral dose 1 mcg/kg
- Heat labile single polypeptide chain undergoes proteolytic clevage irreverisibly binds and blocks cholinergic transmission causing a deadly neuroparalytic syndrome
- Rx: Botulin antitoxin (equine derived against Clostriduim botulinum A,B,E)
- Highly toxic, restricted availability is rapidly absorbed and metabolized to methylmercury crosses CNS
- LD50 of 50 mcg/kg means a dose as little as 0.1ml can result in severe poisoning
- Death of Darmouth inorganic chemist Karen Wetterhahn who spilled a few drops on back of her latex gloved hand, quickly permeated, and absorbed causing severe neurotoxocity and death 10 months later
- Rx: Chelation
VX ("venomous agent X")
- Organophosphate nerve agent has been used as chemical weapon
- Colorless, odorless, low volatility, and high lipophilicity
- LD50 of 0.04mg/kg (10 mg). Death can occur within 15 minutes after absorption
- Blocks acetylcholinesterase enzyme causing excess accumulation of acetylcholine at the neurojunction and cholinergic poisoning
- Rx: Decontamination, Atropine, 2-PAM
- 100 fresh and salt water varieties (pufferlike fish/blue ringed octopus, frogs)
- Heat stable, water soluble found in fish skin, liver, ovaries,intestine, and muscle
- 25 mg (0.000881 oz) expected to be lethal to a 75 kg person
- Neurotoxicity by inhibition of Na-K pump and blockade neuromuscular transmission
- Rx: Supportive measures
LD50 expresses the dose at which 50% of exposed population will die as a result of exposure.
Show References
Background: Sedation and analgesia are key components for mechanically ventilated patients. While significant data exists regarding how to manage sedation and analgesia in the ICU setting, very little data exists on management in the ED.
Data: A prospective, single-center, observational study of mechanically-ventilated adult patients used linear regression to identify ED sedation practices and outcomes, with a focus on sedation characteristics using the Richmond Agitation-Sedation Scale (RASS).
Findings:
- 15% of intubated patients had no sedation or analgesia ordered
- 64% of intubated patients were documented as deeply-sedated (RASS -3 to -5)
- Deep sedation was not only associated with more ventilator days, but also increased mortality, with an adjusted OR of 0.77 (95% CI 0.54-0.94) favoring patients with lighter sedation.
Bottom line: Avoid early deep sedation in your intubated patients as this may be directly associated with increased mortality. Instead, a goal RASS of 0 to -2 should be appropriate for most non-paralyzed, mechanically-ventilated ED patients, extrapoloating from ICU guidelines.
Show References
There is tremendous interest in identifying factors that may influence outcome from sports related concussion.
The strongest predictor of slower recovery is the severity of symptoms in the 1-2 days post injury
-Fewer Sx's in this time period predict a quicker recovery
Pre injury history of mental health problems, depression or migraine headaches predict a longer recovery course
Teenagers might be more vulnerable to having persistent symptoms with greater risk for girls than boys
Having a prior concussion is a risk for having a future concussion
The large majority of injured athletes recover from a clinical perspective within the first month of injury many within the first 10 days
Show References
Anaphylaxis is a life threatening emergency with mortality of up to 2% [1]. Early recognition is imperative and administration of timely Epinephrine is the single most important intervention [2]. While providers may be hesitant to administer epinephrine in older patients due to fear of precipitating adverse cardiovascular events, they may also hesitate in younger patients due to fear of overdose.
Iimmediate administration with any dose available is recommended because:
- the risks of untreated anaphylaxis are greater than the risk of over-treating with epinephrine.
- 20% of Anaphylaxis patients require a second dose of Epinephrine [3].
- The recommended IM dose of 0.01mg /kg was determined arbitrarily.
- The vast majority of epinephrine overdoses are via IV injection at doses 100 - 1000 fold the recommended IV dose [4]
Bottom line:
There are no absolute contraindications (including age) for epinephrine in patients with anaphylaxis. Give the initial dose IM into the anterolateral thigh.
Show References
Full cohort analysis idarucizumab for dabigatran associated bleeding was recently published in NEJM.
This study evaluated the laboratory correction of elevated ecarin clotting time or diluted thrombin time induced by dabigatran and time to either cessation of bleeding (Group A: patients with GI bleeding, traumatic bleeding, or ICH) or time to surgery (Group B: patients requiring surgical intervention within 8 hours).
Findings
Group A (n=301): Median time to the cessation of bleeding was 2.5 hours in 134 patients.
HOWEVER:
- Bleeding cessation could not be determined in 67 patients
- Cessation of bleeding could not be assess in 98 patients with ICH
- Bleeding stopped spontaneously in 2 patients.
Group B (n=202): Median time to intended surgery after infusion of idarucizumab was 1.6 hours.
- Normal hemostasis in 184 patients (93.4%), mildly abnormal in 10, and moderately abnormal in 3.
- Many received PRBC and other blood products during surgery
Laboratory markers:
100% reversal of abnormal ecarin clotting time or diluted thrombin time within 4 hours after the administration
Mortality
- 5 Day: Group A: 6.3% vs. Group B: 12.6%
- 30 Day: Group A: 13.5% vs. Group B: 12.6%
- 90 Day: Group A: 18.8% vs. Group B: 18.9%
Conclusion
Authors concluded thate idaurcizumab is an "effective" reversal agent for dabigatran.
Overall, the findings are more promising compared to the interim analysis that was published in 2015.
Show Additional Information
Show References
- CSF:blood glucose ratio is a useful characteristic in differentiating bacterial meningitis from viral meningitis.
- Normal CSF glucose is at least 2/3 of serum glucose level.
- In bacterial meningitis, CSF:blood glucose ratio is usually <0.4
- Rousseau et al. conducted a study comparing CSF:blood glucose ratio obtained using a bedside glucometer with the laboratory.
- They found the optimal cutoff of CSF:blood glucose ratio using a bedside glucometer is 0.46 compared to 0.44 using the laboratory.
- This proof-of-concept study suggests that a point-of-care glucometer can be used for rapid diagnosis of abnormal CSF:blood glucose ratio in the evaluation of meningitis.
Show References
Hyponatremic Encephalopathy
- Hyponatremic encephalopathy is a true emergency and due to hypoosmolar-induced cerebral edema.
- In contrast to the asymptomatic patient with hyponatremia, treatment of hyponatremic encephalopathy is determined by symptoms and not the duration of hyponatremia.
- Clinical manifestations include nausea, vomiting, headache, confusion, seizures, respiratory failure, and coma.
- Hypertonic saliine is the treatment of choice
- Administer 2 ml/kg 3% hypertonic saline (100 ml in many cases)
- This will typically raise serum sodium 2 mEq/L
- In most cases, a 4-6 mEq/L rise will reverse neurologic symptoms
Show References
Febrile seizures occur in children 6 months through 5 year olds. A complex febrile seizure occurs when the seizure is focal, prolonged (> 15 min), or occurs more than once in 24 hours.
The prevalence of bacterial meningitis in children with fever and seizure after the H flu and Strep pneumomoniae vaccine was introduced is 0.6% to 0.8%. The prevalence of bacterial meningitis is 5x higher after a complex than simple seizure.
From the study referenced, those children with complex febrile seizures who had meningitis all had clinical exam findings suggestive of meningitis. More studies are needed to provide definitive guidelines about when lumbar punctures are needed in these patients.
Show Additional Information
Show References
In patients presenting to the ED with suicidal ideation, physicians should not use currently available risk-assessment tools in isolation to identify low-risk patients who are safe for discharge. The best approach to determine risk is an appropriate psychiatric assessment and good clinical judgment, taking patient, family, and community factors into account. (Level C Recommendation, based upon the quality of the research.)
Show Additional Information
Show References
Catastrophic Antiphospholipid Syndrome (CAPS):
A life-threatening “thrombotic storm” of multi-organ micro & macro thrombosis in patients with antiphospholipid syndrome (known or unknown).
Triggered circulating antibodies (usually by infection, but can be prompted by malignancy, pregnancy, and lupus itself) cause endothelial disruption and inflammation leading to prothrombotic state, commonly with SIRS response.
Mortality is high at an estimated 40%.
Confirm diagnosis with antiphospholipid antibody titers.
Treat ASAP with unfractionated heparin, corticosteroids, and Hematology consultation for plasma exchange and/or IVIG.
Show References
- It most commonly occurs in patients with preexisting pituitary adenomas, but 3 out of 4 patients with pituitary adenomas are unaware of their diagnosis.
- Patients may acutely present with thunderclap headache, with or without visual field deficits or cranial nerve dysfunction. They may also have meningeal symptoms due to extravasation of blood into the subarachnoid space.
- Endocrine dysfunction is common but not readily diagnosed in the ED.
- Symptoms may be triggered by some hormonal treatments (e.g. GnRH agonists for prostate CA), head trauma, angiographic procedures, or anticoagulation therapy.
- CT is diagnostic in only one-third of cases, but can reveal the intrasellar mass in 80% of cases, and therefore should be the initial test. Blood may be missed in subacute cases.
- MRI is the test of choice, with a sensitivity of over 90%.
Bottomline: Keep pituitary apoplexy in your differential when considering SAH or meningitis, especially in the presence of risk factors, and have a low threshold to order an MRI.
Show References
Take Home Point: In patients with diabetic gastroparesis, haloperidol may be an effective adjunctive treatment to prevent hospitalizations and reduce opioid requirements.