On a day when the 355^th mass shooting this year in the USA occurred in San Bernardino, California, it seems appropriate to discuss gun violence.

A recently accepted publication in the American Journal of Medicine compared morality data from the USA to other high-income countries, and found the following:

The US homicide rates were 7.0 times higher than the aggregated rates of all other high-income countries.

• This is driven primarily by a gun homicide rate that is 25.2 higher
• For 15-24 year olds, the gun homicide rate is 49.0 higher

The overall US suicide rate is average

• However, in the USA the firearm-related suicide rates were 8.0 times higher

Unintentional firearm deaths were 6.2 times higher in the US.

The overall firearm death rate in the US from all causes was 10.0 times higher.

Bottom line: As stated in the article: “The US has an enormous firearm problem compared to other high-income countries with much higher rates of homicide and firearm-related suicide.”

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Mechanical Ventilation for Septic Patients in Resource-Limited Settings

• An international team of physicians just published a series of recommendations for ventilatory support of septic patients in resource-limited settings.
• Pearls from these recommendations include:
  • Elevate the head of the bed to 30^o - 45^o
  • Consider tidal volumes of 5 - 7 ml/kg PBW in all patients
  • Use minimum levels of PEEP ( 5 cm H₂O) in all patients with sepsis and acute respiratory failure (unless the patient has moderate to severe ARDS)
  • Lower F_iO₂ to target SpO₂ > 88% or PaO₂ > 60 mm Hg
  • Use lung ultrasound to evaluate pulmonary edema when CXR is not available
  • Consider using SpO₂ to FiO₂ (S/F) as an alternative to P/F when blood gas analyzers are not available

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Question

Patient presents with right elbow pain after a fall. What's the diagnosis and what other injury should you look for?

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Medial elbow pain is common among baseball pitchers and is also seen in other sports including football, javelin and gymnasts.

More than 97% of elbow pain in pitchers is located medially.

The ulnar collateral ligament of the elbow is an important structure in these patients.

http://www.aafp.org/afp/2014/0415/afp20140415p649-f3.jpg

While initially primarily seen in professional throwers, these injuries are now being seen in younger athletes.

Initially, patients may only note changes in stamina or strength of throws.

Later, they will note pain during the acceleration and follow through-phase of throwing

http://stlhealthandwellness.com/wp-content/uploads/2013/02/elbow03.jpg

The Valgus stress test for UCL deficiency is similar to the valgus test for the knee

https://www.youtube.com/watch?v=f6YvPSVk6G8

Treatment: splinting, ice, NSAIDs

Surgical indications: Failure of non-operative treatment with desire to return to same or higher level competition.

Ketamine has been the drug du jour for everything from agitation to pain, but status epilepticus?

Looking at the pathophysiology of seizures, they occur due to an imbalance between excitatory mechanisms (through glutamate at the NMDA receptors) and inibitory mechanisms (at GABA receptors). The mainstay for seizure treatment has been mostly potentiation of the inhibitory mechanisms, but why not inhibit the excitatory mechanisms at the NMDA receptors?

Ketamine is the only NMDA antagonist that has been investigated for refractory status epilepticus, mostly in retrospective small series, with only 3 prospective cohort studies, totaling to 162 patients (110 adults and 52 pediatrics). Variable results were recorded, from studies with complete response in all patients to complete treatment failure, with a total of 56.5% of the adult patients having electrographic response. The optimal bolus dose appears to be 1.5-4.5 mg/kg, with an infusion of up to 10 mg/kg/hour.

Bottom Line? Consider using ketamine in patients who are in refractory status - after benzodiazepines, a 2nd line agent (such as fosphenytoin, valproic acid or levetiracetam) and IV anesthetics have failed.

(NMDA: N-methyl-D-aspartate, GABA: -aminobutyric acid)

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--The role of antibiotics in acute exacerbations of COPD remains controversial in many settings. However, a recent Cochrane review concludes that antibiotics have "large and consistent" benefit in ICU admissions [1]:

• decreased length of hospital stay
• decreased treatment failure
• decreased mortality

--However, patients on antibiotics had increased side effects, are at risk for increased drug-drug interaction (think azithromycin/levofloxacin), and the effect on multi-drug resistance is unclear.

--GOLD Guidelines are a bit more liberal with their recommendations for antibiotics [2], recommending antibiotics based on symptoms or in patients needing mechanical support.

--TAKEAWAY -- if your patient needs BiPAP or ICU, they should also get antibiotics!

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Question

An elderly patient presents with a history of weight loss and chronic constipation. The abdominal Xray is shown below. What's the diagnosis?

This one is tricky so here's a hint: why is the right kidney and psoas muscle so well defined?

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Steroids and Back Pain:

This pearl, https://umem.org/educational_pearls/2805/, by Dr. Corwell reported on the trail published in JAMA that showed that Steroid use does NOT help in the treatment of acute sciatica. But what about just general back pain. Do steroids help with that?

An article published in January in the Journal of Emergency Medicine, http://dx.doi.org/10.1016/j.jemermed.2014.02.010, reported on a randomized controlled trial of prednisone 50mg daily for 5 days versus placebo for the treatment of Emergency Department patients with Low Back Pain.

The study showed that at follow-up there was no difference between the groups in respect to pain, resuming normal activities, returning to work, or days lost from work. More patients in the prednisone group then the placebo group sought additional medical treatment (40% vs 18%).

CONCLUSION: The authors detected no benefit from oral corticosteroids in ED patients with musculoskeletal back pain, and it might actually increase their chance of returning for additional medical care. Just say NO to steroids in back pain.

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Electronic cigarettes have been gaining popularity in the U.S. as a smokeless delivery system for nicotine. These devices require liquid nicotine (e-liquid) that are vaporized and inhaled (vaping).

E-liquid can have nicotine concentration as high as 100 mg/mL, which are diluted prior to use. When ingested in high concentration and in sufficient volume (1 vial = 15 mL) patients can develop significant nicotinic toxicity.  Recently a case of cardiac arrest has been reported after ingesting two 15 ml vial (100 mg/mL).

Nicotine mimics the effects of acetylcholine (Ach) release by binding to nicotinic receptors located in:

• Brain
• Spinal cord
• Autonomic ganglia
• Adrenal medulla
• Neuromuscular junction
• Chemoreceptors of carotid/aortic bodies

Clinical manifestation of toxicity (similar to cholinergic toxidrome) is biphasic with early central stimulation followed by depression. (see table below)

Management: There is no specific antidote or reversal agent. The management of nicotine toxicity focuses on organ-specific dysfunction. 

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There are two main models of Emergency Medical Services (EMS) Systems

Franco-German

• Doctor is brought to the patient
  • Care often provided by emergency physicians
• Based upon the “stay and stabilize” philosophy
  • Fewer transports to the hospital
  • Direct transport to inpatient wards
• Utilizes more extensive advanced technology
• Widely implemented in Europe
• EMS as part of public health organization

Anglo-American

• Patient is brought to the doctor
  • Care provided by emergency medical technicians/paramedics
• Based upon the “scoop and run” philosophy
  • More patients transported to the hospital
  • Brought to the emergency department
• More likely to be found in countries with emergency medicine as a developed specialty
• Widely implemented in English speaking countries globally
  • However, also found in other countries such as in the Arabian Gulf
• EMS as part of public safety organization

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Hook of Hamate Fracture

Rare (2% of all carpal fractures)

Mechanism usually direct blow from a stick sport (golf, hockey, baseball)

Presents with hypothenar pain and pain with gripping activities

Physical examination - local swelling and tenderness to palpation over hook of hamate

Diagnostic test - Hook of hamate pull test

https://www.youtube.com/watch?v=A-mjRnC1yWQ

XR - standard wrist series but add carpal tunnel view

http://openi.nlm.nih.gov/imgs/512/60/2904904/2904904_256_2009_842_Fig1_HTML.png

http://www.cmcedmasters.com/uploads/1/0/1/6/10162094/7851913.png?359

Not to be outdone by the recent FDA approval of Idarucizumab to reverse dabigatran, a new factor Xa reversal agent is under investigation. "Andexanet binds and sequesters factor Xa inhibitors within the vascular space, thereby restoring the activity of endogenous factor Xa and reducing levels of anticoagulant activity, as assessed by measurement of thrombin generation and anti factor Xa activity, the latter of which is a direct measure of the anticoagulant activity."

Design

Two parallel randomized, placebo-controlled trials (ANNEXA-A [apixaban] and ANNEXA-R [rivaroxaban]) were conducted in healthy vounteers to evaluate the ability of andexanet to reverse anticoagulation, as measured by the percent change in anti factor Xa activity after administration.

What they Found

Compared to placebo, andexanet significantly reduced anti-factor Xa activity, increased thrombin generation, and decreased unbound drug concentration in both the apixaban and rivaroxaban groups.

Application to Clinical Practice

1. This drug is not yet FDA approved.
2. These trials were funded by the maker of andexanet (Portola Pharmaceuticals) and supported by the makers of apixaban and rivaroxaban.
3. Studies are needed in patients requiring urgent reversal.
4. The trials looked only at laboratory markers of anticoagulation. We don't know how fast (or the extent of) the reversal activity is in the clinical setting.

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Last month we discussed causes of serotonin syndrome including common ED medications such as cyclobenzaprine (Flexeril), tramadol (Ultram), metoclopramide (Reglan), and ondansetron (Zofran).

Let’s conclude this series and discuss how to treat serotonin syndrome:

• Treatment of serotonin syndrome is mainly supportive.
• Discontinuation of all serotonergic agents is crucial, and may be all that's needed in mild cases.
• In moderate to severe cases, use benzodiazepines and titrate to patient sedation and normalization of vital signs.
  • Avoid droperidol and haloperidol due to their anticholinergic properties that inhibit sweating and dissipation of body heat.
  • Caution if using antipsychotics as neuroleptic malignant syndrome can be misdiagnosed as serotonin syndrome.
• Severely intoxicated patients may exhibit autonomic instability with large and rapid changes in blood pressure and heart rate.
  • This should be managed with short-acting agents, such as esmolol or nicardipine.  
• Aggressive control of hyperthermia associated with serotonin syndrome can potentially minimize severe complications such as seizures, coma, DIC, and metabolic acidosis.
  • There is a limited role for antipyretics as the mechanism is due to muscle tone rather than central thermoregulation.
  • In cases of uncontrollable hyperthermia, intubation and paralytics may be required.
• Cyproheptadine is an antihistamine with anti-serotonergic properties that should be used if no significant response to supportive measures.
  • Adult dosing is 12 mg PO followed by 2 mg every 2 hours if symptomatic. Max 32 mg in 24 hours.
• A case series reported the use of dexmedetomidine for the treatment of refractory serotonin syndrome.

This concludes our 3-part series on serotonin syndrome!

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• Invasive candidal infections can carry a high mortality (up to 40%) and can hard to diagnose
• In the ICU it is important to know which patients are at risk for developing invasive candidal infections

Risk factors for invasive candidal infections

• Critical illness (long ICU stays)
• Abdominal surgery (anastomotic leaks, repeat laporatomies)
• Necrotizing pancreatitis
• Hematologic malignencies
• Solid organ transplant
• Solid organ tumors
• Neonates (low birth wt, preterm)
• Use of broad spectrum antibiotics
• Central lines/PICC lines
• TPN
• Hemodialysis
• Steroid use
• Candidal colinization (urine, sputum)  

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If there weren't enough reasons to avoid opioids, here is another: opioids don't work for low back pain (LBP).

Objective

A well-done, double-blind, randomized controlled trial from JAMA set out to compare functional outcomes and pain at 1 week and 3 months after an ED visit for acute LBP among patients randomized to a 10-day course of (1) naproxen + placebo; (2) naproxen + cyclobenzaprine; or (3) naproxen + oxycodone/acetaminophen.

Intervention

• Nontraumatic, nonradicular LBP of 2 weeks’ duration or less
• All patients were given 20 tablets of naproxen, 500 mg, to be taken twice a day.
  • They were randomized to receive either 60 tablets of placebo; cyclobenzaprine, 5 mg; or oxycodone, 5 mg/acetaminophen, 325 mg. Participants were instructed to take 1 or 2 of these tablets every 8 hours, as needed for LBP.
• Patients received a standardized 10-minute LBP educational session prior to discharge.

Outcome

Neither oxycodone/acetaminophen nor cyclobenzaprine improved pain or functional outcomes at 1 week compared to placebo, and more adverse effects were noted.

Application to Clinical Practice

Among patients with acute, nontraumatic, nonradicular LBP presenting to the ED, avoid adding opioids or cyclobenzaprine to the standard NSAID therapy.

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Designer drugs are structural or functional analogs of controlled substances produced to mimic pharmacological effects of the original compound while circumventing legal restrictions and detection on drug screens. Considered "legal highs" by the public, these highly potent drugs are produced in clandestine laboratories with no regulations for quality control or clinical testing for phamacological effects and thus present major threat to public health. Examples include synthetic hallucinogens (DOM: STP), opiates ( methylfentanyl:china white), stimulants (methamphetamine:crank, MDMA: ecstasy, cathinones:bath salts) and synthetic cannabinoids (spice).

The synthetic cannabinoids are the newest designer drugs and numerous cases of intoxication are being reported including some fatalties.Cannabinoids fall into 3 classes: endocannabinoids, phytocannabinoids, synthetic. Marijuana, the best known cannabinoid is plant derived and its psychoactive effects are mainly due to delta-9-tetrahydrocannabinol (THC) which binds with the endocannabinoid receptors CB1 and CB2 found throughout the central and peripheral nervous system and peripheral organs. The CB receptors interact with opiate receptors which is likely responsible for the analgesic effect.

Since 1984, the John Huffman research group at Clemenson University synthesized over 450 cannabinoid compounds for biomedical reseach known as "JWH compounds". These compounds hold great promise in the investigation of multiple diseases and development of new novel therapies. Over the last several years, these cannabinoid compounds began cropping up sprayed onto herbs marketed in colorful packets and sold on the internet, convienence stores, and head shops. Although clearly labeled as "not for human consumption" considered on the street as a legal alternative to marijuana.

Key Points:

• Common names: Spice, K2, Smoke, Skunk, Purple Haze, Scooby snax, Crazy Monkey.
• JWH 018 (4-5 fold greater affinity for CB receptor than THC), JWH 081,122, 210
• Exact composition of products unknown and ever changing to avoid legal restrictions.
• Cannabinoid dose can vary greatly between products and even within same package "hot spots" are found where the drug is more concentrated.
• Often shown to be contaminated with impurities like beta agonists clenbulterol
• No clinical human studies on effects or any routine detection assays available.
• Clinical effects can vary from commonly described anxiety agitation, tachycardia to sedation and somulence.

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- Anterior shoulder dislocations often require surgical management in young adults due to recurrence, but are less common in pediatric patients, particularly under age 10

- A study this year showed that 14-16 year olds are similar to 17-20 year olds in recurrence risk (around 38%- when non-operative management), and this is especially true of males.

- The recurrence rate is lower in the 10-13 age group, but there are also less dislocations in this group as well, making this group harder to assess

- Remember to consider both chronologic and bone age if you are deciding to refer a patient for outpatient surgery follow up, bone age is more accurate to determine healing and response to non-operative treatment

- Consider early referral for surgical management and counseling regarding recurrence risk in the 14-16 year age group after anterior shoulder dislocations

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Sickle Cell Disease (SCD) is a hemoglobinopathy that is considered a relatively rare disease in the United States, affecting about 90,000-100,000 individuals.

Globally, SCD affects millions, primarily in West and Central Africa.

Acute presentations of SCD include:

• Acute Pain (Sickle Cell or Vaso-occlusive) Crisis
  • Most common presentation in emergency departments
• Severe Anemia
  • Splenic sequestration crisis
  • Aplastic crisis
  • Hemolytic crisis
• Infections
  • Particularly from encapsulated organisms because of a damaged spleen (functional asplenia)
• Acute Chest Syndrome
  • From damaged lung tissues leading to hypoxia
  • A leading cause of death for patients SCD
• Stroke
• Priapism
• Other organ dysfunction including kidney failure and eye problems (retinopathy)

The bottom line: 

• Sickle Cell Disease is a serious, painful and potentially life threatening disease that can cause major damage to multiple organ systems.

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Pain Management in the Critically Ill Patient

• Pain is common, often underappreciated, and routinely undertreated in our critically ill patients.
• Poorly treated pain has been shown to adversely affect both short- and long-term outcomes.
• Key pearls when treating pain in the critically ill:
  • Vital signs should not be used in isolation to assess pain
  • Use a validated assessment tool to objectively quantify pain (i.e., Critical Care Pain Observation Tool)
  • An analgosedation strategy (analgesics before sedative medications) has been shown to decrease duration of mechanical ventilation and decrease ICU LOS
  • Opioids have no maximum or ceiling dose. The appropriate dose is that which controls pain with the fewest side effects.

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