Archive | September, 2012

and now for something completely different

28 Sep

a little low-key fare for Friday.

http://lifeinthefastlane.com/2012/09/help/

Head on over, give it a read.  Smile. Chuckle. Shake your head. How true it is sometimes.

And then… we go pick up the next chart, see the next patient.  Its what we do.  Stay strong, brothers & sisters.

 

References: lifeinthefastlane.com

abdominal seat-belt sign

27 Sep

Nice little article from September’s ACEP News:

‘Seat-Belt Sign’ Indicates Hidden Abdominal Injury Risk

HIGHLIGHTS:

  • prospective study of kids (<18 yo) showing up at EDs with blunt torso trauma from an MVC with 24 hours
  • To scan or not to scan was left to the discretion of the treating physician
  • patients followed up at 1 week

 

  • 3740 kids total
    • 585 (16%) had the seat-belt sign
      • 443 of these kids (76%) got an abdominal CT
        • 19% of these kids who got a CT had some intra-abdominal injury
    • 3,155 (84%) did not have seat-belt sign
      •  1,415 of these kids (45%) got an abdominal CT
        • 11% of these kids had some intra-abdominal injury

 

  • Injuries:
    • GI injuries were most common, occurring in 10% of the seat-belt sign patients and 1% of those with no sign (RR, 9.8)
    • no significant differences between the groups in rates of injury to the spleen, liver, kidney, or pancreas.

 

  • factors associated with a risk for any intra-abdominal injury:
    • seat-belt sign (RR, 1.7; P less than .01),
    • hypotension (RR, 2.6; P less than .01),
    • Glasgow Coma Scale score less than 14 (RR, 2.2; P less than .01),
    • decreased breath sounds (RR, 1.7; P = .03),
    • abdominal tenderness (RR, 1.6; P less than .01),
    • evidence of thoracic trauma (RR, 1.4; P = .03).

 

JUST TO SCARE YOU:

  • 196 patients had seat belt sign but no abd pain/tenderness
    • 103 of these kids got a CT
      • 11 had an intra-abdominal injury
        • 4 (2% of the original 196) needed acute intervention

 

 

BOTTOM LINE:

Abdominal seat-belt sign associated with higher risk of intestinal injury.  Consider further imaging in these kids.  CT in moderation, as always, but this is food for thought.

References: acep news; similar theme article; picture

therapeutic hypothermia: what’s the best way to get ’em cold?

26 Sep

BASIC IDEA:

Take cardiac (ideally v-fib) arrest patients with ROSC, cool ’em to 32-34 degrees Celcius for 12-24 hours, hope for improved neurologic outcomes.

 

HOW DO WE DO THAT?

  • UpToDate review
    • Intravenous infusion of 30 mL/kg of cold (4°C [39°F]) isotonic saline, using a pressure bag to increase the rate of administration, reduces the core temperature by >2°C per hour.
    • One liter of pressure-infused cold saline infused over approximately 15 minutes can drop the core temperature by approximately 1°C. The rate of temperature reduction using this method is comparable or faster than that achieved with endovascular catheters.
    • Surface cooling methods, including ice packs, cooling blankets, cooling vests, and cold water immersion, can reduce the core body temperature by 0.5 to 1°C per hour.

 

  • Article 1:
    • hypothermia was initiated in the ICU using iced Hartmann’s solution, followed by either surface (n=41) or endovascular (n=42) cooling; choice of technique was based upon endovascular device availability
    • Endovascular cooling provided:
      • a longer time within the target temperature range (p=0.02),
      • less temperature fluctuation (p=0.003),
      • better control during rewarming (0.04),
      • a lower 48-h temperature load (p=0.008).
      • less cooling-associated complications [overcooling (p=0.05) and failure to reach the target temperature (p=0.04)]
    • no differences in outcome (mortality, ventilator free days, and neurological outcome)

 

  • Article 2
    • Forty-one cardiac arrest patients; 15 with surface and 26 with endovascular cooling
      • Median time in target temperature range was 19 hours in the endovascular group versus. 10 hours in the surface group (P = .001).
      • Median time to target temperature was 4 and 4.5 hours, respectively (P = .67  –> not so significant).
      • Adverse events were similar

 

TAKEAWAY:

Cold fluids (by IV or special/central endovascular catheter) cools faster than surface techniques (ice packs, cooling blankets, immersion, etc).

Endovascular cooling catheter seems to allow for tighter control of temperature over a longer span (e.g. in the ICU for 12-24 hours).

 

REMINDER WHY OVERSHOOTING PAST MILD HYPOTHERMIA (32 degrees C) IS BAD

 

Submitted by J. Rothstein.

 

References: article on timing; acep recap; article 1; article 2; picture

magnesium in asthma: to use or not?

25 Sep

ROUGH IDEA:

Thought to inhibit Ca influx into smooth muscle.

 

Green SM, Rothrock SGIntravenous magnesium for acute asthma: failure to decrease emergency treatment duration or need for hospitalization.  Ann Emerg Med. 1992;21(3):260.

    • 120 patients, age 18-65 yo
    • all got 125mg methylprednisolone, 02, albuterol q1h
    • study group got magnesium 2 g IV over 20 min
    • hospitalization, length of ED treatment, peak flows were not significantly different

BOTTOM LINE: does not show magnesium helped more than just systemic glucocorticoids and duonebs.

 

Alter HJ, Koepsell TD, Hilty WM. Intravenous magnesium as an adjuvant in acute bronchospasm: a meta-analysis. Ann Emerg Med. 2000;36(3):191.

  • Combined results across 9 studies including 859 patients
  • beneficial in improving spirometric airway function by 16% of a SD
  • No serious adverse events were reported 
  • their conclusion: “Although the clinical significance of this is uncertain, given the safety of intravenous magnesium sulfate therapy and its relatively low cost, it should be considered, absent contraindications, in patients with moderate to severe acute bronchospasm.”

BOTTOM LINE: Showed that magnesium is somewhat beneficial.

 

TAKEAWAY:

  • relatively safe/few adverse events
  • may be helpful; at worst, no benefit.
  • worth considering for refractory asthma (to albuterol, steroids, etc).

 

Submitted by J. Rothstein.

 

ANOTHER RELATED POST.

 

MAGNESIUM (dosing/side effects) QUICK REFRESHER

 

References: you just saw ’em; picture

Difficult Airway Algorithm

24 Sep

Heard AM, Green RJ, Eakins P.

  • Australian anesthesiologists designed an evidence-based difficult airway algorithm and trained their staff in its procedures
  • Training included 1hr “dry lab” using mannequins, plus a “wet lab” using intubated sheep who were being euthanized for medical research

HIGHLIGHTS:
  • First step is always needle cric, because:
    • it is easy to remember,
    • the required equipment is readily accessible,
    • and is a temporizing measure
  • All pathways involve middle step of jet ventilation and stabilization
  • All endpoints involve a cuffed endotracheal device

 

  • Scalpel bougie and neck dissection had the highest success rates (100%).
  • Scalpel bougie was the quickest (39 seconds mean). They observed thousands of these procedures but only reported success rates and time to successful completion for 10.
  • Scalpel bougie is most useful for airways when air cannot be aspirated with needle cric (ie bloody) but external anatomy is still palpable.
  • Melker is their favorite Seldinger technique airway device when compared with 3 others

Submitted by M. Smith.


hair tourniquet removal tip

21 Sep

CUTTING NEEDLES: good for putting things back together, and apparently taking things apart, too…

 

Saw this is a recent ACEP News journal, so proud of the good Dr. Morris for slick thinking, and for getting famous.

 

Check out the link for the article in question:

http://www.nxtbook.com/nxtbooks/elsevier/acep0812/#/16

 

References: you just saw it. click the link already.

Trauma in Hemophilia B

20 Sep

RAGING HYPOTHETICAL:


Your next patient is a 3 yo male with Hemophilia B whose leg was hit by a car at low speed while he was playing in the street. He had soft tissue swelling/abrasion and a negative plain film of the leg.  What do you do now?
 
 

HEMOPHILIA B (QUICK HITS):


Hemophilia B is deficiency of Factor IX. Also known as Christmas Disease. It is x-linked recessive.
 
Severity is based on factor IX activity level at baseline: <1% is severe, 1-5% is moderate, and >5% is mild
 
Trauma deserves special attention because of hemorrhage out of proportion to injury, delayed bleeding, and potential for joint destruction from hemarthrosis
 
Factor replacement should be given asap
 
Factor IX can be given as either recombinant or purified
 
Give enough to increase factor level by 40-50% in cases of single joint hemarthrosis, and >50% in severe hemorrhage or any significant head injury
 
Dose in IU = wgt (kg) x desired percent increase x (1.3unit/kg for benefix or 1unit/kg for alphanine or mononine)
 
A continuous infusion can also be given after the initial bolus, to help maintain factor levels, prevent rebleeding, and allow for less frequent monitoring of levels
 
Consult with hem/onc for specific dosing and monitoring recs
 
Submitted by M. Smith.
References: Hoots WK, Shapiro AD. Treatment of hemophilia. www.uptodate.com. 2012.; picture