A recent retrospective observational study looked at the association of oral antibiotics (primarily fluroquinolones) and tendon rupture.

Outcome data is very interesting for our practice, deviates from traditional teaching.

Population:  1 million Medicare fee for service beneficiaries from 2007-2016 (>65 years old)

Antibiotics queried:  Seven total oral antibiotics of mixed class:

1. Fluoroquinolones (ciprofloxacin, levofloxacin, moxifloxacin)
2. Other:  Amoxicillin, amoxicillin-clavulanate, azithromycin and cephalexin.

Outcome measures:  all combined tendon ruptures and 3 by anatomic site (Achilles, rotator cuff {RC} and other)

Results:  Of the 3 quinolones, only LEVOfloxacin showed a significant increase in risk of tendon rupture (16% for RC) and (120% for Achilles) in a 1 month window. The others did not show an increased risk

Among the other antibiotics, cephalexin showed an increase risk across all anatomic sites.

The authors note that the risk with levofloxacin never exceeded the risk of cephalexin in any comparison!

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Study Question: What is the association of relative hypotension (degree and duration of MPP deficit) in patients with vasopressor-dependent shock with the incidence of new significant AKI and major adverse kidney events (MAKE)? 

• Mean Perfusion Pressure (MPP) = MAP - CVP
• MAKE-14: composite measure of death, new initiation of RRT, or doubling of serum creatinine from the premorbid level at Day 14
• Basal MPP estimated using pre-illness BP readings in the chart, basal CVP estimated using prior echo findings or estimated mean values

Methods:

• Multicenter, prospective observational cohort study with 302 patients
• Notable exclusion criteria:
  • age < 40, trauma as primary reason for ICU admission, active bleeding, unavailability of at least two preillness BP readings, pregnancy, "any condition specifically requiring a higher or a lower blood pressure target in the view of a treating clinician"

Results:

• for every percentage increase in the time-weighted average MPP deficit, the odds of developing new significant AKI and MAKE-14 increased by 5.6% (95% CI, 2.2–9.1; P = 0.001) and 5.9% (95% CI, 2.2–9.8; P = 0.002), respectively.
• Relationships between the risks of developing new significant AKI or MAKE-14 and the percentage of time spent with a MAP < 65 mm Hg were not statistically significant 

Take-aways:

• Critically ill patients in shock who had higher and longer degrees of relative hypotension compared to their baseline BPs had a higher incidence of adverse kidney outcomes
• Sidenote: also consider venous congestion/volume overload when thinking about end-organ damage (e.g. MPP not just MAP)

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With a national shortage of octreotide an alternative treatment plan had to be implemented at our institution for patients presenting with variceal bleeding.

Drug references recommend a continuous infusion of vasopressin at 0.2 to 0.4 units/minute. Dose may be titrated as needed to a maximum dose of 0.8 units/minute with maximum duration of 24 hours to reduce incidence of adverse effects. Administer IV nitroglycerin concurrently to prevent ischemic complications and monitor closely for signs/symptoms of myocardial, peripheral, and bowel ischemia.

Protocol at our institution:

Vasopressin

• Initiate vasopressin at 0.2 units/min.

• Increase by 0.2 units/min if bleeding is not controlled after one hour (max dose: 0.8 units/min).

• If bleeding controlled for 2 hours, can decrease by 0.2 units/min and reassess.

• Limit use to 24 hours.

Nitroglycerin

• Use nitroglycerin infusion to prevent adverse effects from vasopressin.

• Initiate nitroglycerin at 40 mcg/min, titrate by 40 mcg/min to a max dose of 400 mcg/min.

• Goal systolic blood press pressure of 90-100 mmHg.  Do not start nitroglycerin if SBP <90 mmHg.

***Please note the vasopressin dose for this indication is significantly higher than the typical dose of 0.03 units/min we use for shock.***

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Please see attachment for the table of serum insulin levels

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Attachments

• 2012312227_Untitled.pdf (39 Kb)

High dose insulin (HDI) therapy is commonly used in patients with severe beta-adrenergic antagonist and calcium channel antagonist overdose. Hypoglycemia and hypokalemia are commonly known complication of HDI therapy. However, kinetics of insulin in patients who received HDI therapy is unknown.

A 51 year-old man with amlodipine overdose was infused HDI (10 unit/kg/hr) for 37 hours; Serial serum insulin levels were drawn after discontinuation of HDI.

Serum insulin levels are shown in below table

The serum insulin level remained significantly elevated during the first 24 hours (normal range: 2.6-24.9 microU/mL) and gradually decreased over 6 days.

Conclusion

• The supraphysiologic insulin levels persist after discontinuation of HDI where patient may continue to experience hypoglycemia
• These elevated insulin level may allow for more rapid titration or simply discontinue HDI when hemodynamic stability is achieved.

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Attachments

• 2012312232_Untitled.pdf (39 Kb)

Chief complaint:  “My hip snaps when I exercise”

Both athletes and non-athletes may report a “snapping” sound with certain movements

This may affect up to 10% of the population

May be associated with activities than involve repetitive hip flexion

Symptoms may be due to an internal or an external cause

External causes are usually due to a tendon passing over a bony prominence

This can be felt as either an audible sensation and/or even a palpable snap

This may or may not involve pain or discomfort

This is most commonly due to a benign cause

During movements in flexion, extension or combined with internal rotation the iliotibial band may move over the greater trochanter.

Alternatively, the hamstring tendon may pass over the ischial tuberosity

There are several other causes with similar mechanisms

Symptoms are usually minimal and not serious

This can be reproduced on bedside clinical exam

               Ask the patient to identify the area of snapping with one finger which will help with anatomic localization

First line therapy is physical therapy which focuses on:

Improving muscle length if muscle is too tight   OR

Improving neuromuscular activation if problem is due to excessive muscle activation

Young infants (0-90 days) have immature immune systems and are at higher risk for serious bacterial infections, particularly urinary tract infections, bacterial meningitis, and bacteremia. Infants less than 90 days old have an incidence of bacterial infections between 8 to 12.5%, while infants less than or equal to 28 days old have almost a 20% incidence.

Risk-stratification of this group has been a huge focus of research over the past couple of decades to help identify which patients require a full sepsis work-up, particularly in well-appearing infants if a source of fever is identified early. Recent studies have explored the utility of biomarkers in risk stratification in this population. A better ability to discriminate would hopefully decrease unnecessary lumbar punctures, antibiotic use, and hospital admission. Multiple studies have shown procalcitonin is able to outperform CRP for prediction of serious bacterial infections. Kuppermann et al developed a tool to identify low risk febrile infants < 60 days using procalcitonin and ANC. Their prediction rule gave a 97.7% sensitivity, 60% specificity, and 99.6% NPV for serious bacterial infection.  There have been several other studies that have looked harder to detect infections such as osteomyelitis or septic arthritis across all pediatric patients and the data has not been as promising.

Bottom line: Procalcitonin shows promise as part of a risk stratification tool in infants younger than 60 days.  Other studies have failed to show its relevance as a screening tool for osteomyelitis, septic arthritis, renal abscess or community acquired pneumonia.

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The Romberg test is part of the standard neurologic examination. The patient is asked to stand with feet together, hand on hips/sides and the eyes are closed. Vestibular and proprioceptive input is being tested. 

This test is not very sensitive overall, but especially in concussed athletes.

Many concussed athletes are able to stand relatively stable despite their neurologic injury.

In order to better identify postural instability in concussion, we perform 3 separate balance tests (modified balance error scoring system, mBESS).

A) Romberg

B) Single leg stance

21. Standing on the non dominant foot, the hip is flexed to approximately 30° and the is knee flexed to approximately 45°.
21. NonDominant Leg: The nondominant leg is defined as the opposite leg of the preferred kicking leg

C) Tandem Stance

https://www.researchgate.net/profile/Boaz_Saffer/publication/309591285/figure/fig2/AS:669641529626644@1536666390860/Balance-Error-Scoring-System-BESS-performed-on-firm-surface-A-C_W640.jpg

Have patient stand quietly with hands on hips

Have patient close eyes and start 20 second trial

If error occurs tell patient to return to start as quickly as possible

Examples of errors: opening eyes, lifting hands, falling out of position

Antimuscarinic agents (e.g. diphenhydramine) are one of the commonly ingested substances in the US. Lorazepam is frequently used to treat delirium and agitation associated with antimuscarinic toxicity. Although physostigmine is also effective, its use is infrequent due to concerns of safety and provider’s limited experience with physostigmine.

A small blinded randomized clinical trial was conducted to compare physostigmine vs lorazepam for the treatment of antimuscarinic toxicity -delirium/agitation. 

Inclusion criteria

• Age: 10-17 years old
• At least one central and 2 peripheral antimuscarinic symptoms
• Delirium and moderate agitation

Intervention

1. Lorazepam 0.05 mg/kg IV bolus (max 2 mg). this dose could be repeated at 10 min if needed. then a 4 hr normal saline infusion 
2. Physostigmine 0.02 mg/kg IV bolus (max 2 mg; over 3-5 min). this dose could be repeated at 10 min if needed. then 0.02 mg/kg/hr (max 2 mg/h) physostigmine infusion for 4 hours.

Plus administration of lorazepam (0.05 mg/kg) IV bolus (max 2 mg) every 2 hours as needed for continued agitation or delirium (at the discretion of treatment team)

Delirium and agitation were assessed by Confusion Assessment Method for the Intensive Care Unit score (CAM-ICU) and Richmond Agitation Sedation Score

Result

Study duration: March 20, 2017 to June 30, 2020

• 175 patients presented with xenobiotic ingestion. But 19 patients were enrolled
• Physostigmine arm: 9 (47%)
• Lorazepam arm: 10 (53%)

Antimuscarinic agent ingested

• Diphenhydramine: 16 (84%)
• Dicyclomine: 1 (5%)
• Doxylamine: 1 (5%)
• Hyoscyamine: 1 (5%)

Proportion of subject with delirium by CAM-ICU

Prior to first bolus (p >0.99)

• Lorazepam arm: 9/10 (90%)
• Physostigmine arm: 9/9 (100%)

After 1^st bolus (p=0.01)

• Lorazepam: 10/10 (100%)
• Physostigmine: 4/9 (44.4%)

End of 4 hr infusion (p <0.001)

• Lorazepam: 10 (100%
• Physostigmine: 2 (22.2%)

No adverse events noted in both group

Conclusion

• Although this is a small study, it showed that physostigmine is better than lorazepam in treating antimuscarinic delirium and agitation.
• This study provides additional support to the finding from a prior retrospective study (Bruns MJ et al. Ann Emerg Med. 2000;35(4):374-381), which also showed the benefits of physostigmine over benzodiazepines in the management of antimuscarinic overdose associated delirium.

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• Prior studies have shown that ethnic minorities have lower levels of stroke knowledge and lower penetrance of public health stroke education.
• A recent study looked at whether patients’ language preference affects acute ischemic stroke care metrics.
  • 3190 stroke patients at an urban Comprehensive Stroke Center, where 300 (9.4%) had a non-English preferred language
  • They found no difference in:
    • Time from symptom discovery to ED arrival (128 min vs. 161 min for patients with English preferred language, p=0.68)
    • Arrival by EMS (65% vs. 61.3%, p=0.21)
    • Door-to-imaging time (55 min vs. 60 min, p=0.33)
    • Door-to-needle time for thrombolysis (51 min vs. 53 min, p=0.69)

Bottom Line: Patients' language preference does not appear to affect the efficiency of acute ischemic stroke care, especially at experienced high volume stroke centers. 

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PEEP in the Intubated Obese Patient

• Obesity has numerous adverse effects on the respiratory system, most notably a reduction in lung volumes.
• The reduction in lung volumes (i.e., FRC) often result in airway closure and atelectasis.
• The application of PEEP in the mechanically ventilated patient helps maintain alveolar patency by preventing derecruitment.
• Importantly, the typical initial PEEP setting of 5 cm H2O is insufficient for many ventilated obese patients.
• Pearl: In the ventilated obese patient start with an initial PEEP of 10-15 cm H2O.

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Opioid Conversion Updates

Updated in 2018, some clinicians are unaware of the changes to the opioid conversion tables.

When converting between opioids, it is important to remember the following steps:

1. Determine the patient’s level of pain and current response to therapy.
2. Calculate current opioid requirement.
3. Convert the opioid using table above.
4. ASSESS! Combine Steps 1-3 to determine what is most appropriate clinically.  If the patient is suffering from severe pain, using the calculated dose may be appropriate.  If the patient is requesting a switch but is otherwise pain controlled, consider a general dose reduction of 25-50% in the new opioid.
5. Monitor the patient for efficacy and side effects.

While online calculators can be helpful, opioid conversions should be done thoughtfully with a full patient assessment to determine the correct conversion for the individual patient.

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Several studies have described factors associated with peri-intubation cardiac arrest in the adult population. Factors such as pre-intubation hypotension, elevated BMI, and elevated shock index (HR/SBP) have been associated with cardiac arrest following intubation in adult ED patients. Given the differences in anatomy and physiology in children, one may expect risk factors for peri-intubation cardiac arrest to differ in children.

A number of studies have examined factors associated with peri-intubation cardiac arrest in the pediatric population, but these have remained limited to the inpatient setting. These studies have found that, in hospitalized and PICU patients, the factors of hemodynamic instability, hypoxemia, history of difficult airway, pre-existing cardiac disease, and higher number of intubation attempts are associated with peri-intubation cardiac arrest. A paucity of literature exists on this airway complication in pediatric ED patients.

Pokrajac et al. provide the first study on risk factors for peri-intubation cardiac arrest in pediatric ED patients. These authors conducted a retrospective nested case-control study of pediatric patients (ages <18 years) who presented to a tertiary children’s hospital in San Diego from 2009-2017. Cases included patients who had a cardiac arrest within 20 minutes after the start of endotracheal intubation. Authors selected a number of predictors to examine, including age-adjusted hemodynamic variables, capillary refill, pulse oximetry, patient characteristics, intubation-related factors, and pre-intubation interventions.

The authors found the following:

-       Demographic characteristics:

o   Patients with peri-intubation cardiac arrest were significantly younger (<1 year of age), shorter, and more likely to have history of preexisting pulmonary disease.

-       Incident characteristics:

o   Patients with peri-intubation cardiac arrest were more likely to have:

       -Low or unobtainable SBP or DBP

       -Delayed capillary refill time

       -Low (<92%) or unobtainable pre-intubation SpO2

        -More than 1 intubation attempt than controls

        -No paralytic or sedative agent prior to intubation

o   Patients with peri-intubation cardiac arrest were NOT more likely to have increases in age-adjusted HR or pediatric shock index in comparison to controls.

o   The strongest clinical predictor for peri-intubation cardiac arrest was pre-intubation hypoxia or unobtainable SpO2. This fact is supported by children’s increased metabolic rate and thus increased oxygen consumption. This physiologic finding explains the shorter amount of time it takes children to develop acute hypoxia, particularly in the peri-intubation setting.

Bottom line: If planning to intubate a pediatric patient in the ED, keep in mind that pre-intubation systolic or diastolic hypotension, delayed capillary refill time, multiple intubation attempts, and hypoxia in particular may increase the risk for peri-intubation cardiac arrest. Consider providing apneic oxygenation to minimize hypoxemia prior to intubation.

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Ethanol exposure among young children can result in significant morbidity. Infants and young children can be exposed to ethanol in many different ways: exploratory ingestion, mixed in formula-both intentionally and unintentionally, etc. 

A recently published study used national poison data system to characterize the ethanol exposure among infants < 12 months of age.

Results:

Between 2009-2018, 1,818 ethanol exposures among infants were reported. Oral ingestion was the most common (96.7%; n=1738). Annual number of ethanol exposure increased by 37.5% each year. 

Exposure site

• Residence: 96.7% (n=1,758)
• Public are/workplace or school: 1.6% (n=29)

Age

• 0-2 months: 16.3% (n=296)
• 3-5 months: 19.6% (n=357)
• 6-8 months: 18.8% (n=341)
• 9-11 months: 45.3% (n=824)

Clinically significant effects

• Coma: 20
• Hypoglycemia: 16
• Respiratory depression: 15
• Seizures: 13
• Hypothermia: 9
• Cardiac arrest: 4
• Respiratory arrest: 3
• Death: 5

563 infants (31%) were evaluated at hospital

38% (n=214) of the exposures were hospitalized

0-5 months of age 

• higher odds of admission: non-critical (OR: 2.35, 95% CI: 1.41-3.92) or critical care unit (OR: 2.39; 95% CI:1.5-3.79)
• higher odds of serious outcome (OR: 4.65; 95% IC: 3.18-6.79)

Conclusion

Ethanol exposure among infants is increasing each year and associated with serious clinical effects.  

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A 25 year old athlete presents to the ED with right anterior shoulder pain.

Pain radiates into proximal biceps.

It is worse with heavy lifting and especially “pulling” exercises at the gym.

How do we evaluate for biceps tendonitis?

1. Tenderness to palpation in the bicipital groove
2. Speed’s test
3. Yergason’s test

Pathology is often the long head of the biceps

https://physioworks.com.au/wp-content/uploads/2019/12/biceps-tendonitis.jpg

Start by palpating this area and attempt to reproduce the discomfort

Speed’s test

• Arm is supinated and extended and elevated against examiner’s  downward resistance
• https://youtu.be/N00gA4Pvsbw

Yergason’s test

• Arm is placed to patient’s side, in pronation and flexed to 90 degrees at elbow
• Patient attempts to supinate and externally rotate arm against resistance
• https://youtu.be/rQ2Mp6aSi88

To determine if the child is prepubescent, look for the lack of pubic hair, clitoral size, configuration of the hymen, breast development, and axillary hair growth. A Tanner stage of 1 would be consistent with prepuberty.

The proper positioning for the physical exam will allow the child to be comfortable and the examiner to obtain an adequate view including up to one-third of the vagina.

If the child is small enough, they can lay in the parent’s lap. For a larger child, you can have the parent sit in the bed with the patient or stand near the child’s head. Engage child life if available.

The frog leg position with gentle downward and outward traction of the labia at the 5- and 7-o’clock positions provides the optimal view.

The knee to chest position is helpful when further evaluation is needed.

A rectovaginal exam is useful for evaluation of masses or foreign body only and is not routinely needed. Place the examiner’s little finger in the rectum and the other hand on the abdomen and palpate.

The use of a vaginal speculum is rarely needed in prepubertal children; if it is needed, perform the exam under anesthesia.

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Summary

Our group performed a meta-analysis to assess whether it is safe to infuse vasopressor through peripheral venous catheters.  We identified 9 studies with a total of 1835 patients.  The prevalence of complications among the pooled patient population was 9%.  Up to 96% of the complications was extravasation and almost no complications required any treatment.

A few studies reported safe infusion of norepinephrine up to 0.1 mcg/kg/min for up to 24 hours.

In exploratory meta-regression, catheter size 20 or larger was negatively associated with the rate of complications.

We also observed that studies that were published within the past 5 years reported significantly lower rate of complications from older studies.  This suggested that with careful planning and monitoring, it is safe to start vasopressor through peripheral IV.

Limitation

most of the included studies were observational. No studies had enough power to statistically analyze any variables that could predict complications.

Bottom line: we should start vasopressor as soon as indicated, if we have good, reliable IV access.

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• Migraine is the 2nd most common neurologic disorder after tension headache and accounts for more disability than all other neurologic disorders combined.
• Diagnosis is clinical and defined by at least 5 episodes of headache that meet the following criteria:
  • Duration of 4 to 72 hours (when untreated or unsuccessfully treated)
  • At least 2 characteristics: unilateral, pulsating, moderate-to-severe pain intensity, aggravated by physical activity
  • Accompanied by at least 1 symptom: nausea, vomiting, photophobia, phonophobia
• Aura symptoms must be fully reversible and may be visual, sensory, speech/language, motor, brainstem, or retinal.
• Early treatment while the headache is still mild include NSAIDs followed by triptans.
  • Opioids and barbiturates are not recommended due to adverse effects and risk of dependency.
• Preventive treatment is recommended for patients who have at least 2 migraine days per month and whose lives are adversely affected.
  • Common therapies include antihypertensive agents (e.g. propranolol), antidepressants (e.g. amitriptyline), anticonvulsants (e.g. topiramate, valproate), and calcium-channel blockers (flunarizine).

Bottom Line: Migraine is a common and debilitating condition that benefits from early treatment. Consider initiating preventive therapy for patients who experience at least 2 migraine days per month and adverse effects despite treatment.

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