october introduction
TRANSCRIPT
EMRAP.ORG OCTOBER 2021 | VOLUME 21 ISSUE 10
EM:RAP WRITTEN SUMMARY OCTOBER 2021: VOLUME 21, ISSUE 10 1
Editor in ChiefExecutive EditorAssociate EditorPrint Editor
Mel Herbert, MD Stuart Swadron, MD Anand Swaminathan, MD Whitney Johnson, MD
October IntroductionJan Shoenberger, MD and Anand Swaminathan, MD
Case: A 54-year-old man presents with worsening nasal pain. The patient has poorly con-trolled insulin-dependent diabetes and was in the ED 5 days ago with the same presen-tation. At that time, he was diagnosed with “nasal cellulitis,” discharged on trimethoprim/sulfamethoxazole, and is now returning stating it is not getting better. On your exam, you see a red, angry left side of the nose. He has a small (< 1 cm) area of mild fluctuance and induration over the L nasal ala with pustular discharge from a pinpoint opening. The sep-tum is intact and there is no evidence of septal hematoma.
Nasal anatomy review:
Ala, the alar rim, nasal sidewall, columella, glabella
PEARLS
Combination blocks can be helpful when dealing with lacerations or abscesses on the face.
To drain an abscess on the ala of the nose, the following may be used:
Infraorbital block
Anatomy: The infraorbital nerve stems from the maxillary nerve (V2), which is a branch of the trigeminal nerve. It exits the infraorbital ridge through a notch. It is located in the middle of the maxillary area between the lower margin of the eye and the upper lip.
Approach: The nerve can be accessed by going through either the facial skin or intraoral, which is the more common approach.
Start the approach in the area where the upper lip meets the gum above the second premolar on the side you want to anesthetize.
With the patient looking straight ahead, draw an invisible line from their pupil down through the infraorbital margin down to that second premolar.
Successful blocks will result in anesthesia of the lower eyelid, the cheek, the side of the nose, the upper lip, and the upper teeth.
Supratrochlear block
Anatomy: The supratrochlear nerve is also a branch of the trigeminal nerve but it originates from the ophthalmic branch (V1) and lies next to the supraorbital nerve.
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PITFALLS
They both exit through the supraorbital foramen above the eye. The supratrochle-ar nerve travels a bit more medial
A successful block results in anesthesia to the medial forehead and bridge of the nose.
Blocking the border of the nasal ala
Anatomy: The external nasal nerve lies right along the junction of the ala and the face.
Approach: Inject anesthetic at the junction of the nasal bone and the nasal cartilage.
A successful block will result in anesthesia of the side of the nose.
Case conclusion: All 3 blocks were used and the abscess was comfortably explored without distorting landmarks through a pinhole defect using small forceps. About 0.5 cc of purulent fluid was drained and the cavity was irrigated. In this case, a small amount of packing was left in the cavity (although this is controversial). Also, because this patient’s glucose was quite high and his diabetes was not controlled, he was admitted for IV antibi-otics (clindamycin).
Incision and drainage of facial abscesses is important to avoid significant complications.
Potential complications of facial and nasal cellulitis
Cavernous sinus thrombosis, necrotizing infections, brain abscess
Rural Medicine: Infant with Altered Mental StatusVanessa Cardy, MD and Julie Vieth, MD
Case: A 3-month-old boy had a period of apnea followed by a short period of cyanosis with complete recovery. Currently, he is minimally interactive, but moving all four extrem-ities. He appears to have normal tone. There are no signs of trauma. He was noted to be very awake and had not slept during the entirety of the ED visit. He was born at full term but he had some in utero complications. His mom used prescribed buprenorphine as well as amphetamines in utero, and he was admitted for 9 days for neonatal abstinence syndrome with 2 days of hypoglycemia. He was unvaccinated because he had missed his first vaccination appointments.
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PERSPECTIVES
Differential diagnosis for altered mental status (AMS):
Think of broad categories like trauma, toxic exposures, infection, seizure, or neurologic disorders.
Laboratory studies to consider include: complete blood count (CBC), chemistry, urine culture, urinalysis, blood culture, procalcitonin, and a urine drug screen.
Additional diagnostics include head CT and lumbar puncture, when appropriate.
Case conclusion: While admitted, the child’s lack of sleep was noted. He stayed alert but minimally interactive. A detailed chart review revealed a note of concern from child services that mom might be giving the baby buprenorphine. The pediatrician then added a specific drug screen for buprenorphine and it was positive. The baby did well and was placed in protective care.
Take-home messages:
A tincture of time can work in your favor.
Communicating with nurses to get clues from observations might be helpful.
Pay attention to the child's interaction and cry.
Detailed chart reviews are important.
Critical Care Mailbag: Ketamine v. Etomidate in IntubationScott Weingart, MD and Anand Swaminathan, MD
A NEAR database study published in 2020 looked at peri-intubation hypotension with ketamine versus etomidate.
The study used registry data.
There was no randomization of patients to treatment arms.
The primary outcome was incidence of hypotension:
Ketamine 18.3%
Etomidate 12.4%
An absolute difference of 5.9% (95% CI 2.9-8.8%).
The authors conclude that we should not necessarily prioritize ketamine over eto-midate for ED intubation if we are concerned about hypotension.
Registry data is useful when there is a lack of high-quality data from randomized controlled trials (RCTs). However, we already have a well done RCT (Jabre 2009) that showed no difference between the two agents.
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PEARLS
This registry data is flawed for a number of reasons, including a confounding by indication (ketamine was given to the sickest patients) at many sites, and the fact that ketamine was rarely used (operators may not be as comfortable with its use).
In patients who are poorly perfused and/or hypotensive, there are two competing priorities with the sedative/amnestic agent:
Maintain hemodynamic parameters.
Render the patient amnestic of the event (e.g. not paralyzed and awake).
Dose reduction is necessary to maintain hemodynamic parameters, but can compro-mise the second priority.
While etomidate itself does not cause hypotension, by removing the patients endog-enous catecholamines, it will cause blood pressure to drop in patients presenting in extremis. This is true for all sedative and amnestic agents we use for rapid sequence intubation (RSI).
Dr. Weingart describes hemodynamically-stable delayed sequence intubation (DSI):
He notes there is no data to support this approach but it is an extension of the available data.
Importantly, you cannot give ketamine and walk away. You must be continuously monitoring the patient.
Start with a small dose of ketamine (e.g. approximately 0.25 mg/kg IV)
Ketamine will not render a patient apneic.
Monitor for dissociation.
Once the patient dissociates, proceed with a paralytic and intubation.
If the patient does not dissociate, administer additional ketamine and monitor for dissociation.
While doing this, watch blood pressure to see if it drops with administration of ketamine.
Continue resuscitation (fluids, blood, pressors as needed) prior to pushing the paralytic.
Dr. Weingart describes a role of etomidate in neurocritical care intubations (etomidate will not cause spikes in blood pressure which may be deleterious).
The switch from negative to positive pressure ventilation will further add to drops in blood pressure.
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PEARLS
PERSPECTIVES
PERSPECTIVES
Dr. Weingart suggests a target MAP of 80-85 mm Hg prior to intubation.
References:April MD et al. Ketamine versus etomidate and peri-intubation hypotension: a national emergency airway registry study. Acad Emerg Med 2020; 11: 1106-15 https://pubmed.ncbi.nlm.nih.gov/32592205/
Jabre P et al. Etomidate versus ketamine for rapid sequence intubation in acutely ill pa-tients: a multicentre randomised controlled trial. Lancet 2009; 374: 293-300. https://pubmed.ncbi.nlm.nih.gov/19573904/
Related content:CorePendium Chapter: Airway Managemet
Advance Directives – Part 2 Mike Weinstock, MD and Ferdinando Mirarchi, MD
We often have to make decisions without clear, available advance directives.
There have been legal cases of wrongful prolongation of life (ie, the treating physician resuscitated a patient when the patient or family didn’t want it).
In most cases this occurs when an advance directive was not known to the treating physician.
In cases where code status is unclear, physicians err on the side of doing more, pre-suming a patient wants everything done.
There are things physicians can do when a patient comes into the ED to prevent wrong-fully prolonging life against a patient’s wishes.
The ABCD’s of advanced directives
Ask
Check and verify the advance directive information (POLST, DNR, etc).
Check with the patient first if possible (ask them their intentions). This may also mean calling the facility where they came from or trying to reach family
Be clear as to whether or not you are dealing with a potentially reversible condition versus a manifestation of their terminal illness.
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PEARLS
Communicate what the issues are for that patient.
Design the care plan for that patient and communicate it clearly to family and patient.
Document the conversation and your efforts in the medical record to protect yourself and the patient.
Beware of “false agents” or powers of attorney who are not acting in the patient’s best interest.
Remember that patients can change their mind about their status.
Related content:EM:RAP SNACK April 2021 - End of Life Directive Complications
Strayerism: Video Laryngoscopy NomenclatureReuben Strayer, MD
Standard direct laryngoscopy has shortcomings in patients with challenging airway anatomy.
Anesthesiologists had long remedied this problem with fiberoptic bronchoscopes and awake intubation approaches.
Unfortunately, this equipment wasn’t always available in the ED and the techniques were not ones that emergency clinicians were all adept with.
Glidescope™ introduced two technologies:
Video laryngoscopy: placing a camera at the end of the laryngoscope blade which projects an image onto the screen.
Hyperangulated geometry: a steeply curved blade designed not to displace the tongue but to creep over it.
These two technologies are radically different in their importance.
Video is a transformative advance that has changed the way we intubate.
Hyperangulated geometry is a marginal advance that comes with a trade-off com-pared to the standard geometry blades.
It is important to understand the differences between these technologies for intubation.
Traditional direct laryngoscopy (DL) can only be used for direct laryngoscopy.
Hyperangulated geometry video laryngoscopy (HAVL) can only be used for video laryngoscopy.
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PEARLS
PERSPECTIVES
Standard geometry video laryngoscopy (SGVL) can be used for both direct laryn-goscopy and video laryngoscopy.
Dr. Strayer opines that the “DL vs VL” debate is silly when we consider the availability of standard geometry video laryngoscopy (SGVL).
Hyperangulated geometry video laryngoscopy (HAVL)
Advantages:
A “good view” of the cords is easier to achieve.
Less force is required.
This may be important in patients with potential cervical spine injury.
Tongue displacement is not necessary.
Disadvantages
It is more challenging to use a bougie during intubation attempts.
Tube delivery is more challenging (the blade and camera point up and the tra-chea points down).
A suboptimal view makes tube delivery easier (counterintuitive but true due to the geometry at play)
Standard geometry video laryngoscopy (SGVL)
Advantages:
SGVL can be used as a DL or VL device.
It is easy to use a bougie to increase first-pass success.
Tube delivery is easier.
Airway suctioning is easier.
Disadvantages:
More difficult to obtain an optimal view of the cords.
More force is required.
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PERSPECTIVES
Lytics in Stroke Study ReanalysisSalim Rezaie, MD and Anand Swaminathan, MD
The use of thrombolytic drugs in the management of acute ischemic stroke continues to be debated.
Some recent articles reanalyze the results of NINDS and ECASS III.
There are 13 randomized controlled trials that look at the use of thrombolytics.
Eleven trials are negative. They did not show benefit for thrombolysis.
Two studies showed a benefit for alteplase
NINDS (1995): NNT = 8-9 for benefit within 3 hours of stroke onset. NNH (ICH) = 16
ECASS III (1998): NNT = 20 for benefit within 3 - 4.5 hours of stroke onset. NNH = 11
The NINDS Trial had some limitations.
Fragility index = 3 (ie, if the outcomes of 3 patients were changed from benefit to no benefit, the study would lose statistical significance).
A re-analysis by Jerry Hoffman (2009) controlled for a number of factors includ-ing stroke severity (in NINDS, the placebo group had more severe strokes) and pre-existing disability.
It found no benefit to thrombolytic therapy and an increased rate of ICH in groups randomized to thrombolytics.
ECASS III Reanalysis (Alper 2020)
Fragility Index = 1 in original ECASS III
The re-analysis controlled for baseline imbalances in stroke severity between groups that may have biased the ECASS III results.
It found no benefit to thrombolytics in ischemic stroke presenting between 3 - 4.5 hours and an increased rate of ICH in groups randomized to thrombolytics.
Bottom Line: there are no trials supporting the use of thrombolytics in the 3 - 4.5 hour acute ischemic stroke window.
Related content:EM:RAP 2021 June: Rick's Rants: Thrombolytics in Stroke
PCMA Archive - December 2009: A Graphic Reanalysis Of The Ninds Trial
https://ebm.bmj.com/content/25/5/168
EMA 2020 September Abstract 10: Thrombolysis 3-4.5 hours after stroke: trial reanalysis
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Rick′s Rants: ACEP Workforce Revisited Rick Bukata, MD and Peter Viccellio, MD
Rick continues his discussion on the ACEP Workforce Report this time with Dr. Peter Viccellio from Stony Brook University.
Topics include:
Expansion of ED services
Observation medicine
ICU in the ED (many of our patients admitted to ICU have <24 hour stay)
Changing residency standards
Advanced Practice Providers (APPs) in the ED
Pharmacology Rounds: Beers CriteriaBrian Hayes, MD and Gita Pensa, MD
Beers criteria were initially created to curtail the use of certain medications in the nursing home population.
This was eventually generalized to all care settings, although this generalization comes with numerous caveats.
Two important principles for emergency clinicians:
For medications classified as potentially inappropriate but not definitively inappropriate for use, it is important to ask if this medication is the best choice for my patient.
It is important to understand why a medication is included in the criteria and read the rationale behind the inclusion to help guide proper use.
Antihistamines
Avoid first generation drugs (eg, diphenhydramine)
CNS depressant effects
Anticholinergic effects
Slower clearance (longer effects)
Use second generation drugs (eg, loratadine)
Less crossover across the blood-brain barrier
Cetirizine does have CNS depressant effects.
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PEARLS
Epinephrine (in anaphylaxis)
Multiple studies show an increased risk of cardiovascular effects with age, but these risks are far outweighed by the benefits of using epinephrine in anaphylaxis.
Intramuscular administration is generally safer than intravenous route.
Nitrofurantoin
Why is this medication on the Beers list?
It is not effective in patients with CrCl < 30.
It is not good for long-term urinary tract infection suppression as it can lead to hepatic and lung toxicity.
Current recommendation: If you need to treat a geriatric patient with cystitis and they have a CrCl > 30, it is safe to use nitrofurantoin.
Non-steroidal antiinflammatory drugs (NSAIDs)
NSAIDs increase the risk for cardiovascular events and GI bleeding. This risk is increased in the geriatric population.
Naproxen has a better risk profile than ketorolac or ibuprofen.
Use the lowest effective dose for the shortest period of time.
NSAIDs are not absolutely contraindicated.
Opioids
Potential adverse effects: Increased risk of sedation, confusion, constipation and respiratory depression with standard doses.
Use alternate medications, if you can.
Start with a lower dose and escalate as needed.
The standard morphine dose is 0.1 mg/kg may be too much for a geriatric patient.
Low-dose ketamine for pain
Studies to date have not shown any issues.
Consider starting with lower doses (0.1 mg/kg instead of 0.3 mg/kg).
Sulfonylureas
Can cause refractory hypoglycemia due to their long duration of effect, even when not taken in overdose.
Glyburide and glimepiride are longer acting, increasing the risk of refractory hypo-glycemia.
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Glipizide is safer as it has a shorter duration.
There is an Increased risk of hypoglycemia when patients are also taking trimetho-prim/sulfamethoxazole (TMP-SMX).
Medications for agitation
There is an increased risk of ischemic stroke, cognitive decline, and mortality with prolonged use.
References:https://dcri.org/beers-criteria-medication-list/
https://pubmed.ncbi.nlm.nih.gov/31078763/
https://pubmed.ncbi.nlm.nih.gov/30693954/
https://pubmed.ncbi.nlm.nih.gov/30693946/
Neutropenic Fever Jessica Mason, MD and Larissa May, MD
Definitions:
Fever: Temperature greater than 101ºF (38.3ºC) or sustained of 100.4ºF (38ºC) for at least an hour.
Neutropenia: Absolute neutrophil count (ANC) < 1000 with an expected decrease to 500, or an ANC of < 500.
The most common (and deadly) bacterial sources of infection are gram negative bac-teria. There is also a higher rate of resistant organisms and opportunistic infections.
If there is no obvious source of infection, the work-up should include 2 blood cultures (1 from indwelling line, if present), liver function tests, bilirubin, chest x-ray (if upper or lower respiratory infectious symptoms), and respiratory viral panel.
Administer empiric antibiotics as quickly as possible:
Provide gram negative coverage with antipseudomonal activity: cefepime or a carbapenem if concern for ESBL.
Piperacillin-tazobactam is another common choice.
Vancomycin can be considered if an indwelling line is suspected to be the source of infection, or if they are hypotensive or toxic-appearing.
Some patients may need fungal or viral coverage.
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Which patients can go home?
Utilize the CorePendium Calculator: MASCC Score for neutropenic fever
This should only be done in consultation with oncology.
Candidates appropriate for discharge are younger, without comorbidities (eg, COPD), well- appearing, and reliable to follow-up.
Related content:CorePendium Chapter: Neutropenic Fever
Crunch Time EM - Neutropenic Fever
EM:RAP June 2017 Risk Stratification of Neutropenic Fever
EMA 2018 February Abstract 16: Risk Stratification Scores of Febrile Neutropenic Patients in ED
Watchman Procedure Susy DeMeester, MD and Anand Swaminathan, MD
Watchman procedure
A cardiology procedure that eliminates the left atrial appendage, thus reducing the risk of clot formation in patients with atrial fibrillation (paroxysmal or chronic).
Performed via percutaneous access through the femoral artery.
Over approximately 45 days, the myocardium grows over the device that is placed in the appendage.
Patients require anticoagulation for the first 45 days due to increased risk of thrombo-embolic disease, but do not require chronic anticoagulation.
Watchman device versus systemic anticoagulation:
Lower hemorrhagic stroke rate with the device.
Lower cardiovascular mortality with the device.
No difference in ischemic stroke rate.
Watchman procedure complications:
Overall complication rate: approximately 1-8% (most occurring immediately post-procedure).
Cardiac perforation leading to tamponade
Almost always occurs during the procedure
A slow leak from a small perforation is possible but unusual.
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Pericarditis or myocarditis
Local vascular issues at access site
Hematoma
AV fistula
Retroperitoneal bleeding
Stroke (risk is typically increased in the first 45 days)
Device embolization (very uncommon)
EMA September Ultra Ultra SummaryMel Herbert, MD
Abstract 1: Continuous Infusion of Hypertonic Saline in TBI: The COBI RCT
Abstract 3: Reduced Alternative Insulin Dosing in Hyperkalemia: A Meta-Analysis
Abstract 4: Bronchiolitis Interventions in Acute Care: A Meta-Analysis
Abstract 5: Multicentre External Validation of the Canadian Syncope Risk Score
Abstract 6: Pharmacist-Led Penicillin Allergy Assessment and Allergy Delabeling
Abstract 7: Ceftriaxone by IV push and Adverse Drug Reactions in the ED
Abstract 8: Creatinine to Detect Renal Compromise in People Needing Contrast CT
Abstract 9: Impact of the Age-Adjusted D-Dimer Cutoff to Exclude PE: RELAX-PE
October Mailbag: BuprenorphineJan Shoenberger, MD, Reuben Strayer, MD, and Anand Swaminathan, MD
PERSPECTIVES
It is still appropriate to treat patients with buprenorphine despite a lack of follow up or unwillingness to follow up.
Patients learn that buprenorphine works and at some point they will be ready for it.
“Give them a preview of recovery”
Try to figure out why they are “bup-averse”.
You do not need an X-waiver to treat in the ED.