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- Many clinicians use end-tidal CO2 to monitor respirations during procedural sedation or mechanical ventilation
- Typically either the presence (or absence) of a "normal" waveform or the quantitative value is used, however a lot more information can be gathered from the actual shape of the waveform; below are a few examples.
- For more examples of interpreting waveforms, click HERE.
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Radiographs of the sacrum and coccyx in the emergency department (ED) have no quantifiable clinical impact, according to a study published in the American Journal of Roentgenology.
Researchers from Emory University Midtown Hospital and Morehouse School of Medicine in Atlanta, GA, sought to determine the yield and clinical impact of sacrum and coccyx radiographs performed in the ED.
Sacrum and coccyx X-rays performed on 687 consecutive patients over a six-year period in level-1 and level-2 trauma centers (4 total hospitals). The patients’ mean age was 48.1, 61.6% were women. The images were categorized as positive for acute fracture or dislocation, negative, or other.
The researchers then analyzed:
• Follow-up advanced imaging in the same ED visit
• Follow-up advanced imaging within 30 days
• New analgesic prescriptions
• Clinic follow-up
• Surgical intervention within 60 days
The researchers found positive results in 58 of the 687 patients, a positivity rate of 8.4%.
None of the 58 positive cases had surgical intervention.
There was no significant association between sacrum and coccyx radiograph positivity and analgesic prescription or clinical follow-up among the patients evaluated at the level-1 trauma centers.
However at the level-2 trauma centers, 34 (97.1%) of 35 patients with positive sacrum and coccyx radiographs received analgesic prescriptions or clinical referrals. Negative cases were at 82.9%.
Of all cases, 39 patients (5.7%) underwent advanced imaging in the same ED visit and 29 patients (4.3%) underwent imaging within 30 days.
“Sacrum and coccyx radiography results had no significant correlation with advanced imaging in the same ED visit,” the authors wrote. “There was no significant difference in 30-day advanced imaging at the level-1 trauma centers, but there was at the level-2 trauma centers.”
The researchers concluded that routine sacrum and coccyx radiography should not be part of ED practice and that patients should be treated conservatively based on clinical parameters.
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Short Answer: No
Classically, some therapies for headaches are thought to be effective in only certain classifications of headaches, such as triptans in migraines, or oxygen in cluster headaches. This is not necessarily true.
Triptans have been successfully used in cluster headaches, as found in the 2013 Cochrane review.1
More recently, "high-flow" oxygen (referring to 12 L/min of oxygen, delivered through a facemask) has been studied in migraine headaches, with promising results. When compared with placebo (air), oxygen used for 15 minutes was more effective in pain relief and improving visual symptom, with no significant adverse events. 2
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American Thoracic Society (ATS) Conference Highlights
The ATS conference was last week in San Francisco and a few cool articles were presented. They are briefly summarized below:
1. Using a helmet vs face mask for ARDS: Non-invasive ventilation is not ideal for ARDS for a variety of reasons. At the same time, endotracheal intubation and ventilation carries some risks as well. Could a new design of a "helmet" device make a difference? This one center study from the Univ of Chicago suggests that it would: decreased rate of intubation, increase in ventilator free days, and decrease in 90 day mortality. http://jama.jamanetwork.com/article.aspx?articleid=2522693
2. Can aspirin prevent the development of ARDS in at risk patients in the emergency department? Unfortunately, it does not appear to help. http://jama.jamanetwork.com/article.aspx?articleid=2522739
3. Should you start renal-replacement therapy (HD, CRRT etc) in critically ill patients with AKI sooner or later? Seems to have no difference and may actually lead to patients not needing any dialysis. Really a great read if you have time. http://www.nejm.org/doi/full/10.1056/NEJMoa1603017?query=OF&
4. Should I extubate at night? Lastly, probably don’t extubate at night if you can avoid it. Or just be cautious. http://www.atsjournals.org/doi/abs/10.1164/ajrccmconference.2016.193.1_MeetingAbstracts.A6150
The American Academy of Pediatrics has developed a new set of clinical practice guidelines to help better manage and think about patients who have experienced an ALTE (Apparent Life Threatening Event). The term BRUE (Brief Resolved Unexplained Event) will replace ALTE.
BRUE is defined as an event in a child younger than 1 year where the observer reports a sudden, brief and now resolved episode of one or more of: cyanosis or pallor; absent, decreased or irregular breathing, marked change in tone or altered level of responsiveness. A BRUE can be diagnosed after a history and physical exam that reveal no explanation.
BRUE can be classified as low risk or high risk. Those that can be categorized as low risk do not require the extensive inpatient evaluation that has often occurred with ALTE.
LOW risk BRUE:
Age > 60 days
Gestational age at least 32 weeks and postconceptual age of at least 45 weeks
First BRUE
Duration < 1 minute
No CPR required by a trained medical provider
No concerning historical features (outlined in the article)
No concerning physical exam findings (outlined in the article)
Recommendations for low risk BRUE:
-SHOULD: Educate, shared decision making, ensure follow up and offer resources for CPR training
-May: Obtain pertussis and 12 lead; briefly monitor patients with continuous pulse oximetry and serial observations
-SHOULD NOT: Obtain WBC, blood culture, CSF studies, BMP, ammonia, blood gas, amino acids, acylcarnitine, CXR, echocardiogram, EEG, initiate home cardiorespiratory monitoring, prescribe acid suppression or anti-epileptic drugs
-NEED NOT: obtain viral respiratory tests, urinalysis, glucose, serum bicarbonate, hemoglobin or neuroimaging, admit to the hospital solely for cardiorespiratory monitoring
*When looking at the evidence strength behind these recommendations, the only one that had a strong level was that you should not obtain WBC, blood culture or CSF
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The classification of blast injuries was first described by Zuckerman in 1941 and is still widely used today. This system organizes injuries by the mechanism through which they are sustained and classifies them as primary, secondary, tertiary and quaternary. These injuries may occur in isolation or in combination with each other.
| Category | Mechanism | Typical Injuries |
| Primary | Caused by blast wave of overpressure | Tympanic membrane rupture, blast lung, intestinal hemorrhage and rupture |
| Secondary | Caused by flying debris and shrapnel | Blunt and penetrating traumatic injuries
|
| Tertiary | Due to individual being thrown by blast | Blunt and penetrating traumatic injuries
|
| Quaternary | Thermal, toxic, and asphyxiant effects | Thermal burns, chemical burns, exposure to toxins, asphyxiation
|
The term quinary blast injury has also been used to describe delayed effects of explosions, such as infections, radiation exposure, and other toxic exposures.
Author: R. Gentry Wilkerson
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Situations Where ECMO Will Likely Fail
- As many EDs and ICUs begin to develop protocols for the use of ECMO, it is important to note select conditions when this therapy is unlikely to be succesful.
- Chronic respiratory or cardiac disease with no hope of recovery
- OHCA with prolonged no blood flow
- Severe aortic regurgitation
- Type A aortic dissection
- Refractoroy septic shock with preserved LV function
- Stem cell transplant patients
- Advanced age with ARDS
- Prolonged pre-ECMO mechanical ventilation (> 7 days)
- Center inexperienced with ECMO
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https://www.youtube.com/watch?v=sCFOObsx_W4
What is their risk of MI???
Anger outbursts are bad for your heart. Out of 300 patients with an acute MI, just over 2% reported losing their temper within 2 hours of the event. A review of nine studies of rage and cardiovascular events all found an increase in cardiovascular events in the 2 hours preceding an anger outburst. Examples included arguments at home, at work or by road rage. Compared with their usual anger levels, the relative risk of heart attack from a fit of rage was 8.5.
What about those of us who are just fanatics, I mean fans....A recent study of World Cup soccer found that the intense strain and excitement of viewing a dramatic soccer match more than doubles the risk of acute heart attack, particularly in men with known coronary heart disease. This was regardless of the outcome of the match!
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Patients with chronic digoxin toxicity generally have multiple co-morbidities such as renal failure, dehydration, and cardiac failure. Sick patients with chronically high digoxin levels may have more than just digoxin toxicity as the cause of illness.
A New Study
Prospective observational study with the primary objective to investigate changes in free digoxin concentrations and clinical effects on heart rate and potassium concentrations in chronic digoxin poisoning when digoxin immune Fab are given.
What They Found
One to two vials of digoxin immune Fab initially bound all free digoxin confirming Fab efficacy. However, this was associated with only a moderate improvement in HR (49 to 57 bpm) and potassium (5.3 to 5.0 mmol/L).
Application to Clinical Practice
- Elevated digoxin concentrations alone may not be solely responsible for bradycardia and hyperkalemia in the chronic setting.
- Digoxin immune Fab is not a magic bullet in chronic digoxin poisoning.
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Want to learn more about how to read a brain MRI? Here are the basics:
- MRIs are described by signal intensity, as compared to CTs where lesions are described by density.
- A dark lesion on MRI is “hypointense”
- A bright lesion on MRI is “hyperintense"
- The most commonly used MRI sequences are T1-weighted, T2-weighted, FLAIR, and Diffusion-weighted.
- T1-weighted images are good for brain parenchyma.
- Contrast enhanced T1 with gadolinium helps differentiate pathological tissue (e.g. tumors, inflammation, infection)
- T2-weighted images are good for CSF spaces and periventricular white matter.
- Edema from a tumor, subacute stroke or hemorrhage appears bright
- Periventricular white matter scarring from multiple sclerosis appears bright
- FLAIR images are T2 images where CSF is dark. FLAIR is very sensitive to edema and parenchymal lesions.
- Diffusion-weighted sequences are good for cellular swelling.
- Acute ischemia appears bright on Diffusion-Weighted Imaging (DWI) and dark on Apparent Diffusion Coefficient (ADC) maps
- Some neoplasms, abscesses and toxic/metabolic/demyelinating processes can also appear bright on DWI.
- T1-weighted images are good for brain parenchyma.
Stay tuned for more pearls in this series on brain MRI!
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Zika virus has received significant media attention in the US due to its recent link with teratogenicity. But Zika is also associated with critical and life-threatening complications, including death. Differentiating it from other Flavivirus diseases such as Dengue or Chikungunya can be challenging.
Diagnosis
- Clinical -- low-grade fever, maculopapular pruritic rash, arthralgias (small joints of hands and feet), non-purulent conjunctivitis [1,4]
- Serum RT-PCR
- Dengue --high fever, severe myalgias, no conjunctivitis, cytopenia common [2,4]
- Dengue is a hemorrhagic fever, Zika and Chikungunya are not.
- Chikungunya -- high fever, severe polyarthralgias, no conjunctivitis, no hemorrhage [2,4]
Complications
- Guillian-Barre Syndrome (GBS) [1,3]
- Responsible for majority of Zika deaths worldwide
- Estimated at 1 in 4000 cases of Zika in French Polynesian study [3]
- WHO estimates up to 4M cases in the Americas this year (~1k cases GBS)
- Immune Thrombocytopenic Pupura (ITP) [2]
- Thrombocytopenia leading to bleeding. Responsible for lone US death and deaths in Columbia
- Meningoencephalitis, transverse myelitis, fetal microcephaly [2]
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Attachments
Ketamine is often thought to be the induction agent least associated with hypotension in the peri-intubation period. However, reports of hypotension following ketamine do exist, including 2 cases of cardiac arrest. [1] There are limited objective means to predict which patients may have an adverse hemodynamic response.
New Study
A new prospective observational study followed 112 patients in the prehospital setting who received ketamine for rapid sequence intubation. 81 had a low shock index [< 0.9], 31 had a high shock index. [2]
Shock index = HR / SBP
What They Found
Patients with a high shock index were more likely to experience hypotension (SBP < 90 mm Hg) in the peri-intubation period compared to those with a low shock index (26% vs 2%).
Application to Clinical Practice
- This is the first study to evaluate a potential objective predictor for which patients may experience hypotension after RSI with ketamine. But, even with a high shock index, the majority of patients did not develop hypotension.
- These findings should not lead to avoidance of ketamine in these situations, as other induction agents are equally or more likely to cause adverse hemodynamic effects.
- It has been suggested to use lower induction doses in patients at risk for hypotension (with the same or higher paralytic dose). Patients with a high pre-RSI shock index may be the population in which to consider that approach.
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Why are selfie deaths on the rise?
People travel everywhere now with their camera equipped smart phones. Capturing a selfie while travelling is very common. This leads to more distracted people and lack of situational-awareness.
Where and how do these deaths occur?
Selfies taken from a height, on a bridge, near motorized traffic, during thunderstorms, at sporting events and near wild animals
Other information:
- So far in 2016 India has reports more selfie deaths than any other country
- In 2015 more people were killed taking a selfie then by shark attacks
- Countries have taken action by creating no selfie zones in at risk areas
Submitted by Dr. Laura Diegelmann
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Neonatal jaundice- Incidence ~85% of term newborns
Bili levels are EXPECTED to rise during first 5 days of life
Be aware of CONJUGATED hyperbilirubinemias (biliary atresia, infection)
Majority of cases due to increase in unconjugated (indirect) bilirubin 2/2 residual fHgb breakdown and insufficient capacity of hepatic conjugation
Severe hyperbilirubinemia (Tbili >20mg/dL) <2% of term infants
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Acute bilirubin encephalopathy(ABE)- Hypertonia, arching, opisthotonos, fever, high pitched cry
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Kernicterus (5% of ABE)-CP, MR, auditory dysfunction, upward gaze palsy
When to refer for phototherapy/exchange transfusion
- Reference published guides (attached)
- Online calculator- http://bilitool.org/
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A 25 year old patient presents to the emergency department (ED) with a first unprovoked seizure. His ED workup is normal and he is back to his baseline, and you plan to discharge the patient with outpatient follow up within 1 week. The patient is requesting to be discharged on an anti-epileptic drug (AED). What do you do?
Educate the patient about the risk of recurrence, and the possible side effects of AEDs!
The American Academy of Neurology (AAN) specifically addressed this in their 2015 guidelines. A few points to remember:
- The risk of recurrence is greatest within the first 2 years, and occurs in 21-45% of patients.
- The risk of recurrence increases with a remote brain lesion or injury, abnormal EEG, significant brain imaging abnormality or nocturnal seizures.
- AED therapy is likely to reduce the risk of a 2nd unprovoked seizure by about 35% over the next 2 years, but the delay in initiating therapy does not increase the long-term remission risk.
Is it different if the patient had multiple seizures within 24 hours?
Patients presenting with multiple seizures in a 24-hour period were as likely to have seizure recurrence as those presenting with a single seizure, irrespective of etiology or treatment.
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A recent survey looked at resuscitation practices that could help improve survival during in-hospital cardiac arrest
- Monitoring for interruptions in chest compressions
- Reviewing cardiac arrest cases monthly
- Adequate resuscitation training
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Exercise and the heart
Exercise increases the risk of sudden cardiac death (SCD) acutely.
Exercise decreases the risk of SCD in the long term.
Regular physical activity (even as little as 15 mins/day) reduces the risk of cardiovascular disease (CVD).
Up to 15% of MIs occur during or soon after vigorous physical exercise. This is typically in sedentary men with coronary risk factors.
In a 1993 study, in the first hour after heavy exertion, risk of heart attack rose more than 100-fold from baseline for habitually inactive persons. However, for frequent exercisers, this risk rose less than three-fold. Think of snow shoveling after a winter storm.
Both the Physicians’ Health Study and the Nurses’ Health Study show that the risk of SCD during exertion is reduced by habitual exercise.
If you are physically active, stay active. If you are not active, you should be because exercise has innumerable personal benefits. However, it is important to start gradually Some individuals at higher risk need to start under the guidance of a physician.
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The terms and concepts of “waiver of informed consent’ versus “exception from informed consent” are often confused. Within the U.S., these concepts are not the same.
- Waiver or alteration of informed consent is for minimal risk research and requires the following 4 conditions:
- Research involves no more than minimal risk to the subjects;
- Waiver or alteration will not adversely affect the rights and welfare of the subjects;
- Research could not practicably be carried out without the waiver or alteration; and
- Whenever appropriate, the subjects will be provided with additional pertinent information after participation
- Exception from informed consent (EFIC) is permissible for emergency research:
- Rarely used, only for true emergencies
- Recognition that there are times/conditions when informed consent is not feasible
- Length of potential therapeutic window is defined (i.e.- short window)
- Must hold the potential for direct benefit for the subject
- Requires special protections and conditions, in addition to the regular ethical review
- Including a community consultation process
Bottom line:
Waiver of Informed Consent ≠ EFIC
- Exception from informed consent (EFIC) is rarely used and is only for true, life threatening situations. It requires substantial review and special steps to obtain.
- Waiver of informed consent is commonly used for retrospective chart reviews and similar minimal risk research.
These are the rules and regulations for the U.S. The regulations for emergency research in other countries may or may not be similar to these.
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Can NIV be Used in ARDS?
- Mechanical ventilation can cause lung injury and increase patient morbidity and mortality.
- Noninvasive ventilation (NIV) is well-known to decrease intubation rates and improve patient outcome in select disease states (i.e., COPD, acute CHF).
- For patients with acute respiratory distress syndrome (ARDS), NIV may reduce the work of breathing by opening collapsed alveoli, increasing FRC, and improving oxygenation.
- To date, there are only a few RCTs that have evaluated the use of NIV in ARDS.
- Unfortunately, these trials have failed to demonstrate improved patient outcome or decreased intubation rates in patients with ARDS.
- Clinical Bottom Line: Intubate patients with ARDS who are difficult to oxygenate with standard oxygen therapy.
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Typically, if an infant or young child presents to the ED with concern for intracranial hemorrhage (ICH), CT is performed as a rapid diagnostic tool. Now that clinicians are more aware of the radiation associated with head CT, the possible use of ultrasound was studied. Ultrasound is commonly used in the neonatal population for detecting ICH. A study by Elkhunovich et al looked at children younger than 2 years who had cranial ultrasounds preformed. Over a 5 year period, 283 ultrasounds were done on patients between 0 to 485 days old (median 33 days). There were 39 bleeds detected. Ultrasound specificity and sensitivity was calculated by comparing the results with CT, MRI and/or clinical outcome. For significant bleeds, the sensitivity for ultrasound was 81%. The specificity for detecting ICH was 97%.
Only 2 patients in the study were older than 1 year. The proper windows are easiest to visualize in children younger than 6 months.
Bottom Line: The sensitivity of cranial ultrasound is inadequate to justify its use as a screening tool for detection of ICH in an infant with acute trauma, but it could be considered in situations when obtaining advanced imaging is not an option because of availability or patient condition.