Archive | March, 2013

Postpartum endometritis (quick review)

29 Mar

common cause of postpartum febrile morbidity, which is defined as:

  • oral temperature of ≥38.0 degrees Celsius on any 2 of the first 10 days postpartum (excluding the first 24 hours)
  • The first 24 hours are excluded because low grade fever during this period is common and often resolves spontaneously

 

Postpartum endometritis is typically a polymicrobial infection involving a mixture of two to three aerobes and anaerobes from the genital tract. 

Cesarean delivery is the most important risk factor for development of postpartum endometritis.  Additional risk factors for postpartum endometritis include:

  • Prolonged labor
  • Prolonged rupture of membranes
  • Multiple cervical examinations
  • Internal fetal or uterine monitoring
  • Large amount of meconium in amniotic fluid
  • Manual removal of the placenta
  • Low socioeconomic status
  • Maternal diabetes mellitus or severe anemia
  • Preterm birth
  • Operative vaginal delivery
  • Postterm pregnancy
  • HIV infection
  • Colonization with group B streptococcus
  • Nasal carriage of Staphylococcus aureus
  • Heavy vaginal colonization by Streptococcus agalactiae or Escherichia coli

Postpartum fever, tachycardia that parallels the rise in temperature, midline lower abdominal pain, and uterine tenderness are the key clinical findings in women with endometritis, and are present in most women.

Purulent lochia, chills, headache, malaise, and/or anorexia are additional findings observed in some women. 

The diagnosis of postpartum endometritis is clinical and largely based upon the presence of postpartum fever that cannot be attributed to another etiology after a thorough history and physical examination. 

Antibiotic treatments reported to be equivalent to clindamycin plus gentamycin include cefotetan, cefoxitan , ceftizoxime, zosyn, and augmentin.

 

 

Submitted by H. Reed-Day.

 

References: Infections related to pregnancy. Gorgas DL – Emerg Med Clin North Am – 01-MAY-2008; 26(2): 345-66, viii; picture

lidocaine for IO infusion pain

28 Mar

I looked this up again recently, figured I’d save some of you the trouble:

Lidocaine 2%

  • 40mg through the IO catheter over about two minutes,
  • followed by a 10 mL normal saline bolus over five seconds.
  • An additional 20 mg of lidocaine was then administered over 30 seconds.

 

Lidocaine 2%  is 20mg/ml -> so ~2 mL will get you your 40mg dose

 

 

If you’re worried about toxic doses, here’s a refresher:

Lidocaine max dose 4.5mg/kg

for the average 70kg patient:

70kg * 4.5mg/kg = 315mg

315mg / 20mg/ml (for 2% lido) = ~15 ml max

 

ONCE AGAIN:

Lidocaine 2% – use 2 mL slow IO push (over 2 minutes in the referenced study), 10cc NS flush.

May benefit from an additional 1 mL slow IO push of 2% lido.

 

References: JEMS article; picture

continuous vs. intermittent albuterol nebs in asthma

27 Mar

quick breakdown of a cochrane review in November’s Annals:

 

HIGHLIGHTS:

agent in question: albuterol (beta-agonist) nebulization

 

 

Hospital admissions in moderate to severe asthma with…

  • continuous nebs 44/169
  • intermittent nebs 68/172
  • NNT ~ 7

 

continuous nebs improved peak flow rates, which reduced hospitalization rates

 

no significant difference seen in:

  • hypokalemia
  • tachycardia
  • tremors

 

THEIR BOTTOM LINE:

“…in severe exacerbations, continuous nebulization appears to be more beneficial”

 

References: article; cochrane review; picture

Radiation exposure from CT scans in childhood

26 Mar

nice blog post from early January at ALiEM on CT exposure data in kids. click through for a quick read.

 

HIGHLIGHTS:

Exposure to 2-3 CT scans of the head will triple the risk of brain tumors

 

5-10 head CT scans will triple the risk of leukemia.

 

approximately 1 excess case of leukemia and 1 excess brain tumor per 10,000 patients.

 

estimated cumulative absolute risk of being diagnosed with a brain tumor or leukemia 10 years after the first CT scan is 0.01%

 

References: academic life in emergency medicine post; picture

ondansetron (zofran) for kids

25 Mar

Nice quick hits article by Dr. Sharieff in March’s EP Monthly. click through to check it out.

CLIFF NOTES VERSION:

Can ondansetron (Zofran) decrease the need for IV fluids in kids with gastroenteritis? 

(yep.  0.15 mg/kg sublingual tab. hooray, oral hydration)

——

Does the use of ondansetron for vomiting mask serious illness?

(doesn’t look like it ,  in decent N  studies (6k, 34k) in head injury and gastroenteritis kids)

References: epmonthly article; picture

numbers of the day: therapeutic hypothermia goal

22 Mar

keeping it simple for friday.   I sometimes forget these random numbers, so it’ll always be here for you to check. And refresh your memory:

THERAPEUTIC HYPOTHERMIA GOAL TEMPERATURE:

32-34 degrees Celcius

32-34 degrees C

(89.6-93.2 degrees F, if you like Farenheight)

 

NNT (Number Needed to Treat): 6

 

ONCE AGAIN:

32-34 degrees C

 

REMEMBER IT. 32-34.

References: theNNT.com, acepnews.com, uptodate.com, picture

ARDS (Acute respiratory distress syndrome)

21 Mar

RAGING HYPOTHETICAL:

31 year old woman comes in from home with acute difficulty breathing.

 

She has a remote history of pneumonia and resulting respiratory failure requiring intubation. She denies recent viral illness, fever, trauma, or inhalational injury. She has no history of heart failure.
 
On exam she is tripod-ing and working hard to breathe. No rales are heard but she is taking shallow breaths at a rate of 60 per minute.
No signs of trauma to chest, normal pharyngeal exam, no stridor. Cardiac exam normal, blood pressure and heart rate within normal limits.
 
CXR reveals…
 
(patchy bilateral infiltrates without evidence of effusion)
ABG reveals normal pH and normal CO2 and PaO2 of 200 while on non-rebreather
 
Pro tip:
  • if a patient is on non-rebreather (FiO2 = 100%), their blood gas PaO2 is equal to their PaO2/FiO2 ratio.
  • If this number (PaO2) is less than 300 think about ARDS/ALI
 
Key Points:
 
ARDS is associated with significant mortality (up to 45%)
 
Risk factors for ARDS: 
  • Pulmonary infection
  • Sepsis
  • Inhalational injury (smoke)
  • Shock
  • Trauma (lung contusion)
  • Aspiration event
 
Diagnosis of ARDS (via AECC consensus in 1994):
  • Bilateral infiltrates on CXR
  • Absence of clinical signs of CHF
  • Marked Hypoxemia
  • PaO2/FiO2 ratio <300 for Acute lung injury or <200 for ARDS
  • Pulmonary Capillary Occlusion Pressure <18 (unlikely to be useful in ER setting)
 
Management:
  • Intubation to prevent and/or treat impending hypoxemic respiratory failure
  • Low tidal volume (6-8 ml/kg) to minimize further lung injury
  • Increasing PEEP may be useful in the ER to help maintain adequate oxygenation. Increased PEEP may also help stabilize lung volume and prevent further lung injury longer term, but this is not entirely clear.
  • Prone positioning – not something I would necessarily do in the ER but may be worth thinking about if the patient remains hypoxemic despite other efforts.  Call a pulmonologist.
Other things that are out there for refractory hypoxemia:
  • pharmacologic paralysis,
  • oscillating vent,
  • ECMO
Submitted by L. Cunningham. 
——————————————————————————————
References: Michael Donahoe. Acute respiratory distress syndrome: A clinical review. Pulm Circ. 2011 Apr-Jun; 1(2): 192–211. PMC3198645; image