April 2017 | Volume 17 Issue 4

Closed loop obstructions are fairly common in roux-en-y pa-tients with large drops in weight after surgery. These patients will have a dead gut within a few hours.

This patient was transported to the operating room within 90 minutes. The loop of bowel was viable and the patient was dis-charged two days later.

Our ability to create patterns in our mind is excellent. However, it is hard to create patterns if you haven’t seen the case before. Although it is less powerful, we can create patterns by learning from others and reading cases.

Suture: Eversion and Simple InterruptedBrian Lin MD, Jonathan Kantor MD and Zack Shinar MD

Take Home Points

Although wound eversion is not shown to improve out-comes, it reduces tension on the wound.

Single interrupted sutures should be placed in a flask-shaped configuration for best outcome.

The suture knot should be placed to the side of the wound.

How should you place the needle in the needle driver? Place the needle about a third of the way from where the needle con-nects to the suture material and where the needle transitions from a rounded to flattened shape.

How important is it to evert the edges of the wound?

Kappel, S et al. Does wound eversion improve cosmetic outcome? Results of a randomized, split-scar, comparative trial. J Am Acad Dermatol. 2015 Apr;72(4):668-73. PMCID: PMC4950516.

The study found no significant difference in cosmetic out-comes with eversion. However, the sutures were placed us-ing techniques that cause fairly significant wound eversion in general.

Eversion is a sign that you have helped reduce tension across the wound edge.

EM:RAP Written Summary April 2017: Volume 17, Issue 4 1

Editor-in-Chief: Mel Herbert, MDExecutive Editor: Stuart Swadron, MDAssociate Editor: Marlowe Majoewsky, MD

www.emrap.org

Introduction:Bariatric BadnessRob Orman MD and Anand Swaminathan MD Take Home Points

Patients with a history of bariatric surgery are at high risk for complications.

Closed loop obstructions may occur in roux-en-y patients with a large decrease in weight after surgery.

What do you think of when a patient complains of sudden on-set of severe abdominal pain with normal vital signs? Biliary colic, renal colic, ovarian torsion, perforated viscus and pancre-atitis.

The patient had a history of a roux-en-y bypass a year prior. She was asymptomatic and out shopping with her husband and suddenly developed pain and vomiting. EMS was contacted and she was transported for evaluation.

There is a high potential for badness in patients with bariat-ric surgery. The patient had a tender abdomen with peritoneal signs. Swaminathan immediately ordered a CT scan and called the tech and radiologist to expedite the study. Surgery arrived to take the patient to the OR.

How did Swaminathan know the diagnosis? He had a previous case that presented similarly. There was a delay of several hours before diagnosis. The patient was taken to the OR and had a loop of dead bowel resulting in resection and ostomy.

As Evelyn Kim says, if you try to be perfect, you will fail. You will miss a diagnosis and mismanage a case. You will feel horri-ble. The best thing you can do is to be honest about it and make a pact that the next time the situation comes around, you will have learned from the experience.

CASE A woman in her 40s was brought in by EMS with a complaint of abdominal pain. Vital signs were unremarkable aside from tachycardia. The resident went to see the patient and returned 10 minutes later with a concerning history.

EM:RAP Written Summary | www.emrap.org2

The goal of suturing is to restore normal anatomical form and function. One of our biggest problems is tension across the surface of the wound. Tension across the epidermis can lead to gaping and tension across the superficial dermis can result in wound spread or hypertrophic scar formation. Eversion is a sur-rogate marker for tension reduction.

Simple interrupted sutures are commonly placed in the emer-gency department. How can we evert the edges? The simple interrupted suture is highly effective. If you are dealing with a wound with tension or undermining, place deep sutures.

How can you place the best single interrupted sutures?

Load your needle on your needle driver. Enter the skin per-pendicularly and then angle down and away from the lacera-tion. You are forming a flask shape under the skin.

Use your wrist and rotate through the curvature of the nee-dle. The needle is designed to be your friend and make things easier. Come out far on the other side of the wound, pull in a little and come out perpendicular to the skin. Forming a flask shape under the skin will give you some fairly significant wound eversion.

It may be difficult to do this technique in older patients with atrophic skin.

Inversion of the wound leads to more prominent scars. Ever-sion will flatten as the absorbable sutures dissolve. Explain to the patient that the everted appearance will improve.

Where should you place the knot in a simple interrupted stitch?

Pull the knot to the side of the wound. It is very difficult to remove the knot when you have scab and scar tissue in the center of the wound.

What suture should you use?

If you have a good nonabsorbable suture such as nylon, you should be able to handle any wound if you have a variety of siz-es. Colored sutures are nice for wound repair in areas with hair.

You need some absorbable suture such as polyglactin (Vicryl is a trade name).

Fast absorbing plain gut suture is nice for superficial closure of wounds on the face in pediatric patients or patients unable to achieve quick follow-up. These sutures hydrolyze at about the 5 day interval.

Chromic gut can be used for nail bed repair or mucosal suturing.

If you only have polyglactin and nylon available and you are suturing the lip, you can use a 5-0 or 6-0 polyglactin. This tends to be softer because it is braided. You can place a braid-ed, absorbable suture on the outside.

What needle should you use? For the body, you can use an FS2

needle (reverse cutting needle, 3/8” circle). On the face, you can use a P3 needle (precision point reverse cutting needle). If you are working for a wound under significant tension on the back, using a 2-0 absorbable suture on a larger needle can reduce ten-sion and obviate the problem of the needle bending.

What is a reverse cutting needle? The sharp edge is on the out-side of the U shaped curve. You are not going to create a groove as you suture the loop through the skin. Theoretically, a reverse cutting needle makes more sense. However, there is no litera-ture demonstrating a difference in outcomes between cutting needles and reverse cutting needles.

Rural Medicine: Gunshot WoundMel Herbert MD, Jess Mason MD and Vanessa Cardy MD Take Home Points

Management of traumatic cardiac arrest is challenging in the rural setting.

Axillary artery injuries may be difficult to tamponade. You can try manual compression or a device like XSTAT if available.

Cardy is a family doctor who works in a small remote hospi-tal in Quebec. The hospital has 16 acute beds and two crash rooms. Support staff is limited. There are about 7-10 doctors who work during the week and one doctor is on call for emer-gencies. The closest hospital (and closest surgeon and CT scan-ner) is 10 hours away. The nearest trauma center is 16 hours away. Trauma patients are flown out and the process can take at least 6-8 hours.

They were advised that a 19 year old male with a gunshot wound to the right chest would be arriving in 15 minutes. Grady had left for the day but was called back by the overnight physician. The backup call physician also arrived to assist.

What do they have? They do have labs on call at night. It usually takes about an hour to get labs. There is also a blood bank with limited supplies of 6-10 units. They have two ventilators.

Gunshot wounds are rare in this community of 4000 people. There have been gunshot wounds due to hunting accidents or suicide. Cardy has been involved in about 5 cases in the previ-ous 9 years.

The prehospital system is staffed by volunteers with limited training. They aren’t able to give drugs or start IVs.

They prepared the critical access room. The first responders re-contacted and advised that the patient had decompensated.

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He was initially walking and talking but then collapsed in cardiac arrest.

The patient arrived in arrest. He had a 3-4 cm gunshot wound to the right of the sternum on the anterior chest. They tried to start IVs. An IO was placed. Another physician intubated the patient. Cardy placed a chest tube on the right side that drained 300mL. The patient had edema in his axilla. She placed a chest tube on the left side. One of the nurses accidentally stepped on the first chest tube and pulled it out so Cardy had to place a third chest tube. The ultrasound did not show tamponade.

The right axilla continued to swell. Cardy looked in the axil-la and saw a small wound. A shotgun had been used. It was a self-inflicted wound.

They gave the patient 6 units of O negative. The area under the axilla continued to expand. The team discussed the end-point of the resuscitation. It was an hour and a half ambulance drive to reach the plane for transport to a trauma center in Mon-treal. The limited resources of the hospital were already nearly exhausted. If the critical care plane is unable to land, a smaller plane may be required and one of the physicians would have to fly with the patient, decreasing staffing for the next few days. However, it was a young patient. They knew the patient. They knew his family. It is a small community.

What could they do next? The resuscitation continued for 50-60 minutes but they were unable to save him. They cleaned the crash room. Then they debriefed with the first responders. The wound had been self-inflicted and witnessed by the first responders on arrival.

The patient’s family arrived. There were about 35 people in the waiting room. The other patients left the emergency depart-ment. The parents were out of town and they had to break the news to them over Facetime. The patient was placed in an inpa-tient room and the family stayed with him.

What would Kenji Inaba have done?

There is nothing you can do in this situation. The patient has already bled to death and arrested in the field. Your nearest surgeon is hours away. You can’t cross-clamp the aorta for 8 hours. There is no REBOA available.

If the patient had presented to a trauma center, he would have done a thoracotomy on the left side, chest tube on the right and then taken the patient to the OR.

You could try to compress the axillary artery with manual compression. Tourniquets won’t work in this area. An XSTAT device may be an option if available. This is a syringe filled with compressed sponges coated with chitosan that will ex-pand and tamponade bleeding when injected into the wound.

The probability of recovery is low even in a trauma center.

April 2017: Volume 17, Issue 4 | www.emrap.org

A Young Woman with Acute StridorJess Mason MD, Scott Weingart MD, Matt Tabbut MD, and Ryan Naso RN

Take Home Points

Paradoxical vocal cord motion is also known as Munchau-sen’s stridor.

Some cases are thought to be psychogenic but half of patients will have another diagnosis such as asthma or GERD.

Patients may be given ketamine.

Differential diagnosis? Foreign body. Anaphylaxis. Epiglottitis. Angioedema. Laryngeal edema. Pneumothorax.

Racemic epinephrine was given. The airway equipment was ready at bedside.

Bedside ultrasound did not show any pneumothorax or edema. There were no other signs of anaphylaxis.

Lateral x-ray of the neck showed focal edema at the hypopharynx.

How do you evaluate the stridulous patient?

Bring them to a place where you can manage the airway if you need to. Gather all your equipment and RSI medications. Get your failed airway equipment.

Examine the patient. Look in their mouth for angioedema, trismus and foreign body. Is the patient febrile? Do they have signs of toxicity? Listen to the lungs. Is there wheezing? Listen to their neck.

Stridor due to upper airway obstruction is usually inspiratory stridor.

They gave the patient lorazepam. She felt more relaxed. ENT and anesthesia were contacted for fiberoptic endoscopy. The patient was given a lidocaine nebulizer and they prepared for an awake intubation.

When they looked in with the scope, they saw paradoxical vocal cord dysfunction. These patients should have good oxygen sat-uration. However, don’t miss a more serious diagnosis.

CASE A 25 year old female at work developed a tickling sensation in her throat followed by a sensation that she couldn’t breathe. She felt she was only able to draw one in every few breaths in. EMS arrived on scene. Her lungs were clear but she had high pitched stridor. A breathing treatment with albuterol did not help. She was tachycardic with a respiratory rate in the 30s. She was afebrile. Her oxygen saturation as 100%.

EM:RAP Written Summary | www.emrap.org4

This condition was first described as Munchausen’s stridor and was related to stress and anxiety. Not all of these cases are driven by psychology. About half will have another underlying condition such as asthma or one that irritates the vocal cords like GERD.

You can use 5ml of 1:1000 epinephrine (1 mg/mL), put it in the nebulizer and give it to the patient.

If they still have stridor and you are suspicious the cause is not organic, you can take a look with a short rhinoscope. This is a skill we all should have. Prepare for it like you would an awake intubation with topical anesthetic. Spray a nostril with topical anesthetic. Use viscous lidocaine as lubrication. You can use a nasal trumpet to dilate the nostril.

You won’t see any unusual anatomy aside from the vocal cords held in adduction throughout the patient’s respiratory cycle. Paradoxical vocal cord dysfunction is the airway emergency that isn’t. It is a functional disorder of the vocal cords. The etiology is not well understood. It is often attributed to psychiatric dis-orders. It often presents as a conversion disorder. Even though you know it is psychogenic, they have no volitional control. It may sometimes be a Munchausen’s disorder. Have sympathy for these patients.

Treat them like they have a real respiratory disorder. Try non-in-vasive interventions and anxiolytics. Keep the patient in a place where you can intubate them if you are wrong. Have the patient take a deep breath and count from 1 to 10 in a single breath. Alter-natively, patients can blow through a straw. This might help open up the vocal cords. If all else has failed, you can give ketamine.

If the patient is given ketamine and has paradoxical vocal cord dysfunction, their symptoms should immediately improve. The patient will maintain their respiratory drive with ketamine, so if you are wrong, the patient is set up for an awake intubation or nasopharyngoscopy. Have everything you need to manage the patient’s airway before you give the patient ketamine.

The ketamine worked.

Trauma Surgeons Wild:Chest Tubes Big and SmallMizuho Spangler DO and Kenji Inaba MD

Take Home Points

Chest tubes are used primarily for trauma patients or pa-tients with viscous fluids requiring drainage.

Smaller tubes with a one way valve may be an option in patients who will be discharged home.

The complication rate of percutaneous chest tubes is sim-ilar to open thoracostomy, but the complications tend to be more severe.

Tube dislodgement is a common complication. Make sure the tube is secure before moving the patient.

A healthy 21 year old male presents with a moderate size pneu-

mothorax. There is no associated hemothorax or empyema. Vi-tal signs are good. He is not in any respiratory distress. What criteria should you use to determine a Heimlich valve versus a chest tube?

Chest tubes are used primarily for trauma patients or patients with viscous fluids that need to be drained. Smaller catheters with a Heimlich valve are used primarily for spontaneous pneu-mothoraces or iatrogenic pneumothoraces after biopsy.

In general, smaller tubes with a one way valve are designed for patients who will be sent home and thoracostomy tubes are placed in trauma patients who will be hospitalized.

Chest tubes have changed. Previously, all patients had a large bore chest tube placed. There has been a shift towards less in-vasive procedures.

Inaba, K et al. Does size matter? A prospective analysis of 28-32 versus 36-40 French chest tube size in trauma. J Trauma Acute Care Surg. 2012 Feb;72(2):422-7. PMID: 22327984.

Complications such as empyema, retained hemothorax and subsequent interventions are the same regardless of size of the chest tube used.

The most common tube size used is a 28. In the OR, they will use 20 French. Pediatric patients may have a smaller size tube.

Will we eventually transition to percutaneous chest tubes?

There is some literature on using these. However, these are retrospective case series. There are no randomized trials. The data so far is weak but some do consider placing these.

The complication rate appears similar to open thoracostomy but the types of complications vary. The wire can migrate to undesirable places such as the pulmonary hilum and subclavian.

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ABCD.

Activation. Let the blood bank know early.

Blood products.

Complications.

Drugs.

When should you initiate massive transfusion? Physician judgement, an ABC score of 2 or more (points for penetrating mechanism of injury, systolic BP of 90 or less in the ED, heart rate of 120 or more or positive FAST exam) or other tools.

There are bleeding issues and clotting issues. Studies suggest the coagulopathy in trauma starts within minutes. Does transfu-sion approximating whole blood treat the coagulopathy or just prevent it from getting worse? You are treating the coagulop-athy and maintaining levels to avoid developing coagulopathy. The literature indicates that plasma has special properties that may reduce endovascular leak. Plasma provides fibrinogen, C1 esterase, antiplasmins and possibly some other factors.

How can you predict which products the patient needs at each point in time? Some are using TEG. Does it result in better out-comes? TEG is a way of measuring whole blood coagulation. There are some advantages. However, even large centers may struggle with its use. The blood must be transported from the patient to the device within a few minutes for it to be accurate. The device must be calibrated frequently (several times day). If you are using it frequently, it may be a good investment. If it is not used frequently, it may not be worth your time.

Blood products. In a massive transfusion, you have blood, plate-lets and plasma hanging. How is it done?

The priority is red blood cells to provide volume and oxygen carrying capacity.

Next, platelets for clotting capacity. The platelets current-ly available through plasmapheresis are packed in plasma. A pack of apheresis platelets is equivalent to 6 packs of plate-lets; adjust your proportions accordingly. Don’t cool platelets as it lowers their functionality.

The PROPPR study did not show mortality benefit at 24 hours with 1:1:1 compared to 1:1:2 ratios (plasma:platelets:red cells). It did show benefit in death due to exsanguination but this was not the primary endpoint. 1:1:1 is a goal but it may be difficult to achieve at many sites. Plasma is usually the limiting factor.

Plasma. AB plasma is the universal donor and difficult to ob-tain. You may be able to use A plasma but this is suboptimal. Plasma is fresh frozen which can lead to a delay before it is ready for use. Many blood banks will keep a small amount of FFP thawed and ready to go.

Before we start using this in trauma patients, we need to de-termine how efficient it is at draining air and blood, the me-chanics of placement and the associated complication burden.

Are there any tips to secure the Heimlich valves?

The initial dressing overlying the opening should be as se-cure as possible. You can place some Vaseline soaked gauze at the opening. This can be followed by a dressing that keeps the tube in a neutral position. Place a gauze pad underneath to prevent kinking of the tube. This can be overlaid by more gauze and taped down securely.

Any thoracic tube should be secured to the chest wall at a second point. The tape can be formed into a leash.

Seal the connections with tape.

Tube dislodgement is a common complication. Check to make sure it is securely placed prior to moving the patient.

How long should patients be observed prior to discharge? There is no good evidence based answer. It depends on where you work, where the patient lives, the reliability of the patient and ability to return for complications. However, if you have ob-served the patient for several hours, repeat chest x-ray shows re-expansion of the lung and the patient remains asymptomatic, it is not unreasonable to discharge the patient if they will be able to return easily.

The ABCD of Massive TransfusionRob Orman MD and Tom DeLoughery MD

Take Home Points

Massive transfusion is replacement of greater than one blood volume in 24 hours or greater than 50% of blood volume in 4 hours.

Although TEG may be used to tailor transfusion to the pa-tient’s needs, it may not be feasible at some sites.

The priority in massive transfusion should be red blood cells and then platelets.

Massive transfusion can lead to hypothermia. One unit of packed red blood cells lowers the temperature by 0.25 de-grees Celsius

10 units of cryoprecipitate will raise the fibrinogen by about 100.

What is massive transfusion? Replacement of greater than one

blood volume in 24 hours or greater than 50% of the blood vol-ume in 4 hours.

EM:RAP Written Summary | www.emrap.org6

When do you de-escalate or stop the massive transfusion? Most will stop when the patient becomes hemodynamically sta-ble or bleeding is controlled.

Should we be using cryoprecipitate? This is an interesting prod-uct. It has factor VIII, Von Willebrand factor and fibrinogen. It is mainly used as a source of fibrinogen. Some feel that fibrinogen should be greater than 150 for good hemostasis. If the patient continues to bleed after substantial product transfusion or you are stopping the massive transfusion, check the fibrinogen. If it is less than 150, give cryoprecipitate. 10 units of cryoprecipitate will raise the fibrinogen by about 100. The use of a 1:1:1 ratio appears to decrease the need for fibrinogen. This may be due to the presence of fibrinogen in plasma.

Complications of massive transfusion.

Hypothermia. Enzymes work best at body temperature. A decrease in the temperature to 35 degrees decreases coagu-lation factor function and impairs platelets. At 30-32 degrees, there is a massive fibrinolytic response. One unit of blood can lower the core temperature by 0.25 degrees (C). If you get 10 units of blood, your temperature will drop by more than 2 de-grees. You can use blood warmers if available or a Bair hugger to keep the patient warm.

There are a lot of hypothetical complications of blood trans-fusions; acidosis, hyperkalemia, hypocalcemia and hypother-mia. Plasma has a lot of citrate, which chelates calcium. The body normally has substantial capacity to metabolize citrate but this may be decreased in cardiac arrest.

Drugs.

Tranexamic acid. The CRASH-2 trial was an interesting trial. Early on, patients bled less without an increase in clots. How-ever, if the tranexamic acid was given later than 3 hours after injury, they did not have benefit and may have had harm. It is unclear why. It may be that the initial coagulopathy from the trauma improved and the TXA was no longer helpful. De-Loughery recommends giving TXA to all trauma patients who arrive within 3 hours. For those outside the window or those with rebleeding, there may be some other markers to guide administration. TEG showing fibrinolysis or persistent oozing may be an indication.

Does TXA cause clots? It doesn’t seem to be that thrombo-genic. What are contraindications? Hematuria is worrisome because a clot stone may develop. DIC. However, it has a pretty good therapeutic index.

Should TXA be part of a massive transfusion protocol for any source of bleeding aside from trauma? Data is very limited. There is a study ongoing on use in massive post-partum hemorrhage. It may be useful in patients with liver disease and fibrinolysis.

PCC (prothrombin complex concentrate): These contain all of the useful factors as well as protein C and S. Currently, its use seems to be limited to the ‘Hail Mary’ when the patient bleeds despite all interventions. DeLoughery will use it if the patient continues to bleed after several rounds of 1:1:1 trans-fusion. The evidence is anecdotal.

What happened to factor VII? Enthusiasm ran ahead of the data. It made the labs look great but probably wasn’t help-ing hemostasis. The theoretical benefit didn’t pan out and it seems to have harmed patients (with clotting complications).

Chronic Digoxin ToxicityRob Orman MD and Bryan Hayes PharmD Take Home Points Patients with chronic digoxin toxicity may have comorbid

conditions contributing to their bradycardia and hyperka-lemia.

Sick patients with elevated digoxin levels should be hy-drated. Improved renal function will decrease the digoxin and potassium levels.

Does Digibind work for chronic digoxin toxicity? Patients with

chronic digoxin toxicity usually have a lot of comorbid condi-tions; renal failure, dehydration and cardiac failure. It can be hard to determine why the patient is sick.

Chan, BS et al. Efficacy and effectiveness of anti-digoxin antibodies in chronic digoxin poisonings from the DORA study (ATOM-1). Clin Toxicol (Phila). 2016 Jul;54(6):488-94. PMID: 27118413.

This was a prospective observational study investigating changes in free digoxin levels and its clinical effect on heart rate and potassium levels in chronic digoxin toxicity.

They took patients with chronically high digoxin levels and signs of digoxin toxicity such as bradycardia or renal failure and gave them anti-digoxin Fab.

Patients received 1-2 vials of Digibind and the investigators evaluated a number of variables such as a heart rate and po-tassium. The Digibind worked in lowering the digoxin levels but there were only modest improvements in heart rate and potassium levels.

Elevated digoxin levels may not be solely responsible for the clinical picture of bradycardia and hyperkalemia in the chronic setting. Fab may not be a magic bullet.

If the patient is sick and their digoxin level is high, start to hy-drate them. Improving renal function will lead to a drop in the digoxin level and potassium level. If the patient has significant

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dysrhythmia or hyperkalemia, go ahead and treat with digoxin Fab fragment. Save treatment for symptomatic bradycardia or other dysrhythmias. Contact the Poison Control center or your toxicologist.

Atraumatic Spinal NeedlesRob Orman MD and Bill Reed MD

Take Home Points Cutting needles may lead to increased risk of post-dural

puncture headache.

Blunt tipped needles result in a lower incidence of post-spinal headache.

Although the technique is similar to cutting needles, the skin should be punctured with an 18 gauge or other nee-dle prior to insertion of blunt tipped needles.

Stop using cutting needles for lumbar punctures. A lot of peo-

ple have issues with the blunt tip needles our anesthesiology colleagues have been using for years. These are not cutting nee-dles. We want to divide the dural fibers rather than slice them to decrease the risk of post-dural puncture headache.

Don’t make your colleagues take care of your post-dural punc-ture headache. We don’t do blood patches and have to call an anesthesiologist.

A blunt tipped needle results in a lower incidence of post-spi-nal headache.

Straus, SE et al. How do I perform a lumbar puncture and analyze the results to diagnose bacterial meningitis? JAMA. 2006 Oct 25;296(16):2012-22. PMID: 17062865.

This review article proposed that using an atraumatic needle may decrease the chance of post-LP headache.

Castrillo, A et al. Postdural puncture headache: impact of nee-dle type, a randomized trial. Spine J. 2015 Jul 1;15(7):1572-6. PMID: 25794941.

This was a randomized controlled trial comparing the atrau-matic (Sprotte) needle versus the traumatic (Quincke) needle. Post-puncture headache occurred in 22% with the traumatic needle versus 9% in the atraumatic needle.

There are usually two types of atraumatic needle available. The Sprotte, which has an oval hole on the side and the Whitaker, which has a rectangular port on the side.

How do you use a blunt tip needle? The needle is usually small-er. Typically, kits come with a 20 or 22 gauge needle. It looks the same. You need to poke a hole in the skin with an 18 gauge

needle. Make a hole deep enough that a little bit of blood comes out. It requires a little more strength to get the spinal needle in than the cutting needle. The technique is the same.

Tung, CE et al. Cost comparison between the atraumatic and cutting lumbar puncture needles. Neurology. 2012 Jan 10;78(2):109-13. PMID: 22205758.

The authors estimated a savings of $26 per patient and 10 million dollars saved by the health system in the US if atrau-matic needles were used.

Is the flow rate of CSF the same?

Pelzer, N et al. Are atraumatic spinal needles as efficient as traumatic needles for lumbar puncture? Neurol Sci. 2014 Dec;35(12):1997-9. PMID: 25139108.

They found the flow rate from atraumatic needle was not slower than traumatic needles. In some cases, the flow rate was faster.

Little LabsRob Orman MD and Tim Horeczko MD

Take Home Points

Obtaining lactic acid in your sick pediatric patients may change your disposition and level of care.

Most children seen in the emergency department do not need any laboratory work. Don’t send routine laboratory tests as a part of triage.

Albuterol use is associated with increased lactic acid levels.

D-dimer has not been studied in children as a rule out strategy for pulmonary embolism.

BNP may have utility in patients with established cardiac disease.

Lactic acid in pediatric patients. Lactic acid is helpful in sepsis

and trauma. If you are getting labs on a child that you are wor-ried about, it is fine to get a lactic acid. There have been some studies demonstrating utility of lactic acid in pediatric patients. Lactic acid of 4.0 mmol is considered the cutoff for need for ICU level of care or increasing morbidity and mortality.

Scott, HF et al. The utility of early lactate testing in undifferentiated pediatric systemic inflammatory response syndrome. Acad Emerg Med. 2012 Nov;19(11):1276-80. PMID: 23167859.

They found that most patients did not have elevated lactic acid. However, elevated lactic acid was significantly associat-ed with increased risk of organ dysfunction.

EM:RAP Written Summary | www.emrap.org8

Shah, A et al. Diagnostic accuracy of a single point-of-care pre-hospital serum lactate for predicting outcomes in pediatric trauma patients. Pediatr Emerg Care. 2013 Jun;29(6):715-9. PMID: 23714761.

They found that prehospital lactate level was higher in pediat-ric trauma patients who required critical care.

Bai, Z et al. Effectiveness of predicting in-hospital mortality in criti-cally ill children by assessing blood lactate levels at admission. BMC Pediatr. 2014 Mar 28;14:83. PMID: 24673817.

They found a high blood lactate level at admission was predic-tive of in-hospital mortality.

Lactic acid can be helpful in children, especially with sepsis. Use your best judgment. If you feel like the child will be able to go home after fluids, you don’t need to send the lactate. Obtain-ing lactic acid in the sick child who will be admitted may change your level of care. A child with a lactic acid of 5 mmol/L will likely go to the PICU as you are worried about occult shock.

Most children seen in the emergency department do not need any laboratory work. If you are sending routine laboratory test-ing as part of triage, please reconsider. Laboratory work should be directed toward a specific clinical question.

A mnemonic to troubleshoot an elevated lactic acid: LAC-TATES.

L – Liver. Liver disease affects metabolism of lactate in the Cori cycle and leads to an increase in lactate.

A – Albuterol. Albuterol has been associated with elevated lactic acid levels. It is thought that beta adrenergic receptor stimulation increases cAMP mediated gluconeogenesis. The increased glucose is converted to pyruvate and then lactate.

C – Can’t breathe. Anyone who is critically ill with increased work of breathing. About 30% of our cardiac output can go into our diaphragm when work of breathing is increased.

T – Toxins. An array of toxins can increase lactic acid.

A – Alcohol. We commonly see this in adults.

T – Thiamine deficiency. Consider in malnourished or cachec-tic patients.

E - Epinephrine. This may be seen with epinephrine drips.

S – Shock or seizure.

D-dimer. There is increased recognition of pulmonary embolism in children. Can we use D-dimer in children? D-dimer has not been studied in children as a rule out strategy for pulmonary embolism.

Significant pulmonary embolism in children is rare. If they do have a PE, there is usually a reason for it. 98% will have one risk factor such as recent surgery, cancer, sickle cell disease,

indwelling catheter, rheumatologic disease, prothrombotic medications or obesity. In comparison, about 30% of pulmo-nary embolism in adults is idiopathic.

BNP. Maybe. This may have utility in children with established cardiac disease.

Mayer, KO et al. B-type natriuretic peptide in the emergency diagnosis of critical heart disease in children. Pediatrics. 2008 Jun;121(6). PMID: 18519452.

This study demonstrated that BNP could be helpful in children with established cardiac disease to demonstrate whether the acute presentation was due to a respiratory cause or underly-ing cardiac dysfunction. The cutoff was the same as that used in adults: 100pg/mL. If the level was below the cutoff, their presentation was unlikely due to cardiac dysfunction. High-er levels were more likely to be due to cardiac dysfunction. However, elevated BNP isn’t as specific as we think.

For example, a 3 year old girl with a history of a Fontan pro-cedure presents with upper respiratory symptoms. You might consider a BNP to determine if cardiac dysfunction is the like-ly etiology.

ComaRob Orman MD and Wendy Chang MD

Take Home Points Coma is a spectrum of dysfunction of awareness and

arousal.

The Glasgow Coma Scale can provide limited description in a patient with decreased level of consciousness.

The FOUR scare assesses eye response, motor response, brainstem reflexes and respiration.

Use central stimuli to assess response to painful stimuli. Movement in response to peripheral stimulation can be difficult to interpret.

What is coma? Coma is a spectrum of dysfunction of awareness and arousal. On one end is brain death with lack of any function and the other end is emergence from coma with patients who are aware of their environment and able to interact. We are usu-ally talking about patients in between these extremes.

CASE A comatose patient is brought to the emergency department. They are not opening their eyes or interacting. The patient was found lying in the street in a comatose state.

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The ENLS (Emergency Neurological Life Support) protocol pro-vides recommendations for approaching this situation. This is a series of protocols that were developed to assist in care of these patients in the first hours after a neurologic emergency. They were developed the Neurocritical Care Society and written by emergency physicians and neurointensivists.

The protocol starts with the ABCs. The next step is the neuro-logic assessment.

How do you do the neurologic assessment in a patient that is comatose? This involves four parts.

Look at the level of consciousness. Do they open their eyes spontaneously? Do they open their eyes to verbal or tactile stimuli? Do they open their eyes at all?

Look at the brain stem function, motor function and breath-ing pattern.

We are all familiar with the Glasgow Coma Scale. However, it can provide a limited description in a patient with a decreased level of consciousness. For example, a patient with a MCA stroke who is aphasic would have a GCS of 11. A patient who is intoxicated and a patient with a brainstem lesion might both have a GCS of 3 but the outcomes will be very different.

The FOUR (Full Outline of UnResponsiveness) is a 17 point scale that assesses eye response, motor response, brainstem reflexes and respiration.

Wijdicks, EF et al. Validation of a new coma scale: the FOUR score. Ann Neurol. 2005 Oct;58(4):585-93. PMID: 16178024.

The vestibulo-ocular reflex or doll’s eyes. If the patient is co-matose without injury to the brainstem, the eyes shift left and right with movement of their head. If the patient is unable to do this, they may be awake or may have a cranial nerve deficit. If this reflex is absent, it implies a bad brain injury.

Does the patient localize to a painful stimulus? We should use central stimuli such as sternal rub or axillary pinch as this can help determine ability to localize. If the patient pulls their hand away with painful stimuli applied to the nailbed, it can be difficult to determine if they are localizing or flexing in re-sponse to pain.

A patient presents in a coma. Do a primary survey and the ABCs. Check glucose. Naloxone. C-spine. Assess level of con-sciousness, motor, brainstem and respirations. Obtain a fo-cused history (time course, alcohol, drugs, meds and trauma).

The differential diagnosis. If you find a focal deficit on your exam, you might be concerned about a structural cause of coma such as a large intracerebral hemorrhage. If the exam is non-focal, you might be concerned about a metabolic cause such as hepatic encephalopathy.

We often need to obtain brain imaging to rule out less obvious causes of coma. Although it is low yield, we do occasionally find cases we are surprised by.

Paper Chase 1:Propofol, Ketofol, and the Non-argumentSanjay Arora MD and Michael Menchine MD

Take Home Points A combination of ketamine with propofol had a similar re-

spiratory adverse event profile compared to propofol alone.

Ketofol may be administered with the agents mixed to-gether in the same syringe or by a bolus of one medication followed by titration with the other.

Although hypotension is more common with propofol, it tends to be transient.

Ferguson, I et al. Propofol or ketofol for procedural sedation and anal-gesia in emergency medicine – the POKER study: a randomized dou-ble-blind clinical trial. Ann Emerg Med. 2016 Nov;86(5):574-582.

The bottom line: a combination of ketamine with propofol had a similar respiratory adverse event profile compared to propo-fol alone with equally high satisfaction and efficacy.

FOUR Score Eye Response 4 = eyelids open or opened, tracking, or blinking to command 3 = eyelids open but not tracking 2 = eyelids closed but open to loud voice 1 = eyelids closed but open to pain 0 = eyelids remain closed with pain Motor Response 4 = thumbs-up, fist, or peace sign 3 = localizing to pain 2 = flexion response to pain 1 = extension response to pain 0 = no response to pain or generalized myoclonus status Brainstem Reflexes 4 = pupil and corneal reflexes present 3 = one pupil wide and fixed 2 = pupil or corneal reflexes absent 1 = pupil and corneal reflexes absent 0 = absent pupil, corneal, and cough reflex Respiration 4 = not intubated, regular breathing pattern 3 = not intubated, Cheyne-Stokes breathing pattern 2 = not intubated, irregular breathing 1 = breathes above ventilator rate 0 = breathes at ventilator rate or apnea

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Ketofol has been increasingly discussed in the literature. Side ef-fects of propofol include respiratory depression, apnea and hypo-tension. Side effects of ketamine include emesis, hypersalivation and emergence reaction. These side effects are dose dependent and it is thought that using a combination of propofol and ket-amine will reduce the likelihood of side effects from both agents.

There are two ways to administer ketofol; mix the agents to-gether in the same syringe or you can give a dose of ketamine up front and then bolus with a 0.5mg/kg of propofol.

This article focused on respiratory safety. This was a double blinded randomized controlled trial including adults requiring deep sedation. Patients with contraindications to either one of the drugs such as high ICP, severe coronary artery disease and egg and soy allergies were excluded. The doctors were given a syringe that either contained 100mg of ketamine and 100mg of propofol or 200mg of propofol.

The primary outcome was a composite including any bad re-spiratory event; desaturation, depressed respiratory rate less than eight, apnea, laryngospasm, need for bag-valve-mask ven-tilation or airway positioning. 573 patients were enrolled in the study. They found a similar rate of adverse respiratory events; 9% in the propofol group versus 7% in the ketamine group.

They also examined secondary outcomes.

Hypotension occurred in 7% of the propofol group versus 1% in the ketofol group. However, the hypotension was transient.

Patient satisfaction was similar for both groups.

Procedural success rates were similar.

Emergence reactions were more common with ketofol.

Pain was less at 30 minutes in the ketofol group: 0/10 versus 3/10.

The time until discharge was longer in the ketofol group.

The results of this paper are in keeping with previous studies. This is the largest study to date. It is multicenter utilizing provid-ers of differing levels of experience and included a wider mix of procedures.

Both of these agents are safe for emergency medicine practi-tioners to use. Both work well. You don’t have to feel compelled to use one over the other.

Paper Chase 2:The Oxygen Middle PathSanjay Arora MD and Michael Menchine MD

Take Home Points A randomized controlled trial showed that maintaining

oxygen saturation of 94-98% in critically ill ICU patients was associated with better clinical outcomes than with an oxygen saturation of 98-100%.

The number needed to treat was 11.

However, the study was stopped early limiting utility. Girardis, M et al. Effect of conservative vs conventional oxy-

gen therapy on mortality among patients in an intensive care unit: the Oxygen-ICU randomized clinical trial. JAMA. 2016 Oct 18;316(15):1583-1589. PMID: 27706466.

The bottom line: this randomized controlled trial demonstrates that maintaining an oxygen saturation of 94-98% in critically ill ICU patients was associated with better clinical outcomes than an oxygen saturation of 98-100%. However, this study was stopped early, diluting the results.

There is considerable controversy about how much oxygen is enough and how much is too much. We are all familiar with the neg-ative effects of hypoxemia. There is evidence that hyperoxemia is also bad. Effects of hyperoxemia on the lung include VQ mismatch-es, pulmonary edema and the development of interstitial fibrosis.

Studies in neonates have demonstrated better outcomes with room air resuscitation compared with 100% FiO2. A trial in STEMI patients showed that supplemental oxygen administered when the patient was not hypoxemic was associated with larger myocardial infarct size. Surgical literature shows that higher over-all mortality is associated with high flow oxygen peri-operatively.

The authors of this study conducted a single center open label randomized controlled trial of 480 ICU patients. The indica-tions for ICU admission were broad. Patients had to have an expected ICU stay of 72 hours. Patients with COPD and severe ARDS were excluded.

The routine care group was allowed to have a PaO2 of up to 150 mmHg to maintain an oxygen saturation of 97-100%. Patients in the intervention group were allowed to have a PaO2 up to 100 mmHg to keep the saturation 94-97%. The key outcome of inter-est was ICU mortality with multiple secondary outcomes.

What did they find? The intervention and control groups were pretty well balanced after randomization. The ICU mortality was 20.2% in the usual care group and 11.6% in the restrictive oxygen group. This is a number needed to treat of 11. In-hospital mortal-ity also differed by 10% across the study arms; 33% versus 23%.

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The difference in mortality seemed to be driven by a higher incidence of developing bacteremia, shock and liver failure in the control group compared to the restrictive group. There are some animal models that have predicted this effect of oxygen on the immune system but human data is limited. There was no difference in the rate of new respiratory failure, which might have been predicted by what we think we know about the det-rimental effects of high O2 on lung tissue.

What does it mean? These are very preliminary findings from a single site trial that was stopped early because they couldn’t find enough eligible patients. This should give us pause. The authors conclude that more data is needed. You should know about this but you don’t have to change your practice based on this very early trial.

Paper Chase 3:4 vs 1 Sono View for PTXSanjay Arora MD and Michael Menchine MD

Take Home Points There is no advantage of the four view chest ultrasound

compared to one view for diagnosing pneumothorax.

The sensitivity of ultrasound for clinically significant pneumothorax is 93%.

Helland, G et al. Comparison of four views to single-view ultrasound

protocols to identify clinically significant pneumothorax. Acad Emerg Med. 2016 Oct;23(10):1170-1175. PMID: 27428394.

The bottom line: there was no advantage of the four view compared to one view for chest wall ultrasound for diagnosing pneumothorax. The sensitivity for clinically significant pneumo-thorax was 93%.

Ultrasound use is growing in emergency medicine. It is espe-cially helpful in the FAST exam in trauma patients. Many per-form an eFAST including an exam of the lungs. Air rises and a chest x-ray of a supine patient on a backboard may miss a pneu-mothorax whereas an ultrasound placed on the chest may be able to detect it.

This can be done in one of two ways; with a single view of each hemithorax (at the highest point of the chest wall) or 4 views of each hemithorax (moving the probe downwards towards the bed to look for small pockets).

This was randomized controlled trial to compare the test char-acteristics of the two methods. Patients from a level 1 trauma center that had a plan for CT after trauma were randomized to either the one view or four view lung ultrasound by “creden-tialed” MDs. These were physicians who had performed 25 ul-trasounds before.

260 patients were enrolled over two years. 49 patients (19%) had a pneumothorax and half of these were deemed clinically significant. The paper was unclear what distinguished clinically significant pneumothoraces but most of these patients were ad-mitted and received a chest tube.

The sensitivity for clinically significant pneumothoraces was 93% for the one view and 93% for the four view ultrasound. Specificity was close to 100% overall. The sensitivity drops when all pneumothoraces were considered. However, these tended to be small or apical pneumothoraces that did not re-quire intervention.

If you want to perform an eFAST, you don’t need to do the four view technique. Although this isn’t a perfect test, it is a good use of ultrasound.

In the one view ultrasound, the probe is placed in a longitudi-nal orientation on the midclavicular line in the third intercostal space. Visualization of lung sliding (sparkling or shimmering) in-dicates no pneumothorax.

Paper Chase 4:Lysis for PE in PEASanjay Arora MD and Michael Menchine MD

Take Home Points Rapid administration of 50 mg IV tPA was effective at re-

storing spontaneous circulation in pulseless electrical ac-tivity due to massive PE.

20 out of 23 patients were alive at a mean follow-up of 22 months.

No patient experienced a major bleeding event although the small sample size might not demonstrate an increase in bleeding.

Sharifi, M et al. Pulseless electrical activity in pulmonary embolism

treated with thrombolysis (from the “PEAPETT” study). Am J Emerg Med. 2016 Oct;34(10):1963-1967. PMID: 27422214.

The bottom line: rapid administration of 50 mg of IV tPA was effective at restoration of spontaneous circulation in pulseless electrical activity due to massive PE.

Resuscitating cardiovascular collapse with a PEA rhythm is challenging. You must consider the underlying etiology of the PEA arrest rather than just running down an algorithm. One etiology is massive PE. This raises the question of whether tPA might be beneficial. tPA is not associated with better clinical outcomes when administered indiscriminately to people with undifferentiated PEA. However, it may be indicated if the arrest is thought due to a PE (about 5-10% of PEA arrests).

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The authors assessed the effects of low dose tPA on clinical outcomes on patients with PEA proven to result from pulmo-nary embolism. They looked at a single site registry of 23 con-secutive patients who got tPA during cardiac arrest. All of the pa-tients got 50mg of tPA over 1 minute during CPR. The majority already had a diagnosis of PE prior to the arrest but a few were confirmed after the arrest. 17 of the patients received tPA in the emergency department. The rest were distributed through the hospital, including one who got it in the radiology suite.

What did they find? tPA was administered on average within 6 minutes of CPR. ROSC returned quickly, within 2-15 minutes following tPA in 22 of 23 patients. Only 2 patients died in the hospital. A third patient died 15 months later due to cardiac ar-rest. 20 out of 23 patients were alive at a mean follow up of 22 months. No patient experienced a major bleeding event.

What does it mean? The AHA gives the administration of tPA for arrest due to PE a class IIa recommendation and these find-ings seem to affirm this.

The 85% survival rate is probably higher than reasonably ex-pected. This may be due to the required confirmation of pul-monary embolism for inclusion. If a patient came into the ED with suspected or highly suspected PE in arrest and died, they would not receive the confirmatory study for inclusion in the denominator. This makes tPA look better than it probably is.

The absence of major hemorrhage is not as surprising as you might think. Most of the literature suggests major bleeding rates of 2-3% when tPA is used for indications other than stroke. This may not be seen in a small sample size of only 20 patients.

Consider pulmonary embolism in PEA arrest. If the clinical probability is high or if the patient has a known PE, 50 mg IV tPA over a minute is a reasonable action to take.

Paper Chase 5: Prehospital Shock IndexSanjay Arora MD and Michael Menchine MD

Take Home Point Use of vital signs in the prehospital setting was not shown

to effectively predict which patients will need massive transfusion.

Pottecher, J et al. Prehospital shock index and pulse pressure/heart

rate ratio to predict massive transfusion after severe trauma: ret-rospective analysis of a large regional trauma database. J Trauma Acute Care Surg. 2016 Oct;81(4):713-22. PMID: 27648770.

The bottom line: the authors attempted to predict which pa-tients will need massive transfusion before they arrive at the hospital, but unfortunately the indices measured fell short of providing reliable triage data.

Bleeding remains the number one cause of preventable death in trauma. Proponents of a 1:1:1 transfusion ratio say the evi-dence shows it will save lives. However, you don’t want to be too aggressive because blood products are hard to come by and it can be technically difficult depending on your location.

Who needs massive transfusion? Technically, it is someone in whom you predict will require at least 10 units of packed red blood cells in the first 24 hours. How are you supposed to pre-dict this? Sometimes it is easy. Most of the time it is less obvi-ous. Once the patient arrives and you can assess them or see labs, it is easier. However, this takes time.

The authors looked at a large database to see if they could find a predictor based on vital signs in pre-hospital setting to help guide us down the massive transfusion pathway prior to arrival or lead to diversion to a higher level of care. They looked at the shock index (heart rate/systolic blood pressure) and a newer hemody-namic index of the pulse pressure/heart rate. The pulse pressure is the systolic blood pressure minus the diastolic blood pressure.

This paper relied heavily upon statistics. They calculated ROC curves for both indices and tried to control for unmeasured vari-ables and missing data. They ultimately found “moderate cor-relation” between both values and the need for massive trans-fusion. However, it is difficult to find any particular cutoff that accurately predicts the need for massive transfusion.

What are the best values? Basically, if the shock index (heart rate/systolic blood pressure) is greater than 1 or the pulse pres-sure/heart rate is less than 0.5, the chance is higher the patient will need massive transfusion. They didn’t find what they were looking for. There is no number with adequate sensitivity and specificity to act on to predict massive transfusion. This is a good refresher on trauma vital signs.

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ways. You can call your specialist for endoscopy. Or you can try to remove it yourself with a Foley catheter.

Candidates for removal in the ER have a single flat blunt ob-ject in the object, no underlying esophageal pathology and the foreign body has been present for less than 72 hours. The esophagus can’t be totally obstructed or you will be un-able to pass the Foley. The most common complication is ep-istaxis. There have been no cases of perforation in the litera-ture. It is safe. This technique is able to remove the coin 88% of the time.

How do you do this?

You need an 8-12 French Foley catheter, a syringe, a saline flush and airway equipment at the bedside. Fill the balloon with barium. This will let you determine the foley balloon is past the object by shooting an x-ray.

Although much of the literature is based on the technique without sedation, Sacchetti recommends light sedation with propofol. Ketamine can lead to hypersalivation and laryngo-spasm.

Estimate the length by holding the Foley from their mouth to the distal esophagus. You can pass the Foley through the mouth or the nose. Inflate the foley balloon and pull back.

The child can be in semi Fowlers at the start of the procedure. Once the foley catheter is in, place the child in slight Trende-lenburg and onto their side. After each attempt, sweep the mouth for the coin.

Remember to deflate the balloon before you try to remove it.

Critical Care Mailbag: How to Secure a CricRob Orman MD and Scott Weingart MD Take Home Point ET tubes used for cricothyrotomy should be secured. A listener asks, “If I use an endotracheal tube for the cricothy-

rotomy, how do I secure it?”

There is no great answer. This is why the ICU doctors get pissed off. It is not a stable airway. You can tape the tube down with a 2 inch piece of tape split in half at both ends. You can wrap half of it around the ET tube on each side. The respiratory therapist is usually good at taping the tube in place. Some have tried to suture it in place like a chest tube.

How long should the ET tube be left in the patient’s neck? These should probably not be left in place for prolonged periods

Annals of Emergency Medicine:A Penny For Your ThoughtsJess Mason MD and Al Sacchetti MD

Take Home Points Handheld metal detector wands can be used to look for

ingested metal foreign bodies in pediatric patients.

Foreign bodies may sometimes be removed by using a Fo-ley catheter.

Pediatric foreign body ingestion. How do you manage a swal-lowed coin?

Most get an x-ray. However, you can also use the hand held metal detector from security to wand the child and determine where the foreign body is. This is pretty reliable. Coins in the esophagus are oriented flat to the AP direction and will likely be detected with the metal detector. Once it gets into the stomach it may orient in a different direction and be more difficult to detect. The sensitivity is about 99% for a coin but drops for other metallic objects. The greater the density the metal, the more likely the wand is to detect the object.

If the child is symptomatic, they should have an x-ray. If the object localizes to the chest with the wand, they should be imaged as well.

If the alarm sounds below the costal margin, the object is below the esophagus. If it is in the high epigastrium, you need to get an x-ray.

If the coin is in the esophagus and the child is asymptomatic, you may observe them. A time period of 12-24 hours is rea-sonable to see if it will pass into the stomach. There is about a 30% chance that it will pass depending on the size and loca-tion of the coin. It does need to come out, however, as even an asymptomatic coin can result in necrosis and perforation.

If the child is symptomatic, such as with coughing or chok-ing, the coin needs to come out. This may be done in two

CASE A 9 year old male ingested two magnets from a board game. These stuck together leading to a jejunoileal fistula and bow-el perforation. The management is straightforward. The child needs a surgical consult.

CASE A child presents after ingesting a coin. The child coughed brief-ly after the incident and is now well appearing.

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of time. However, the concern that these will lead to subglottic stenosis is a myth. These patients don’t necessarily need to be taken to the OR for trach. You can use fiber optics to intubate the patient from above.

VisualizationRob Orman MD, Mel Herbert MD, and Trudi Cloyd MD

Take Home Points Athletes with structured, dedicated mental imagery prac-

tice have demonstrated quantitative improvement in their sport compared to their colleagues without.

This technique can be used in emergency medicine to im-prove comfort with less common procedures or stressful patient cases.

The most effective visualization techniques are the most vivid.

There is power in your ability to mentally see your success.

Athletes routinely use visualization techniques as a part of their training to achieve success.

Cloyd used visualization as an athlete. She had dedicated time after practice to sit on the field and think about a certain move or shot. She pictured stealing the ball from the opposing for-ward and moving it back up field. She practiced the move over and over again until it was burned into her mind with such confi-dence and calm that she could perform it regularly on game day.

Visualization is an untapped resource in emergency medicine. This is mentally simulating a task in such exquisite detail that you are able to learn or perfect skill. Sport psychologists have used this for years. It is thought that the neural pathways re-sponsible for patterning and motor memory can be fine-tuned without actual movement.

Athletes with structured, dedicated mental imagery practice have demonstrated quantitative improvement in their sport compared to their colleagues without. Functional MRI studies show significant activation of the motor cortex when activities are visualized. This is the same area that fires during the actual execution of the activity.

How does this apply to emergency medicine? We do things that require multiple complex moves. There are benefits for all levels of training. It provides confidence for critical procedures. It can maintain competency in skills that we rarely perform such as crash cricothyrotomy or thoracotomy.

How do you this? Find a quiet space, mentally and physically. Close your eyes and relax. Take a few deep breaths. Think through a specific skill or scenario step-by-step in the correct speed.

For example, consider a crash cricothyrotomy. All efforts at ventilating the patient have failed. Picture your resuscitation room and a patient in florid respiratory distress. You use beta-dine. You have your scalpel in your hand and are feeling the neck for the cricoid membrane. Make your vertical cut for direct visualization. Probe with your finger along the ridges. Your view is obscured by blood. Play attention to the timing. Feel the adrenaline. Visualize this through your own eyes. First person visualization is more effective than third person visualization. Cut through the membrane and extend the ex-cision laterally. There may be some spray of blood. Call for bougie loaded with a 6.0 tube.

The most effective visualization techniques are the most vivid. You want to record as much information as possible.

Acknowledge your weakness and the areas you feel most nervous.

Practice visualization as consistently as possible for the best results. It doesn’t need to be more than 5 to 10 minutes. It will improve your skills if you believe it will work.

You can do this anywhere and anytime. Try it.

Hot and Bothered: An Agitated PatientStuart Swadron MD and Billy Mallon MD

Take Home Points Agitated patients need prompt sedation and control as

they are a danger to themselves.

Naloxone administration in a patient with opiate and sym-pathomimetic ingestion may result in extreme agitation.

The differential diagnosis of the hyperthermic, agitated patient is broad and includes toxicologic emergencies, in-fectious disease, thyrotoxicosis, environmental exposure, serotonin syndrome and neuroleptic malignant syndrome.

Midazolam has faster onset with IM administration than lorazepam or diazepam.

The clock is ticking when agitated patients present and taking

control is of the highest urgency. These patients are a danger to themselves. We sometimes talk about medicating them to protect staff but the main reason to give medications is that the patient is a danger to themselves. They have urgent medical needs. They need an EKG, you can’t get one. They need a CT scan, you can’t get one. They need IV access, you can’t get it.

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Some patients may demonstrate adrenergic excitement after naloxone administration, even if opiates weren’t present. This may be seen in intoxicated and septic patients. Although nalox-one does not have a specific adrenergic effect, there may be an increase in circulating catecholamines resulting in hyperventi-lation, tachycardia and hypertension. Naloxone is a pure opioid antagonist.

Avoiding the adrenergic surge is a reason to consider using lower doses of naloxone. If the patient is blue and facing intu-bation, give the 2mg dose. If not, give them the smaller dose to ease them out.

Patients with opiate overdose on the streets may have been using a speedball; heroin mixed with cocaine. When you re-verse the heroin overdose with large doses of naloxone, you are left with cocaine and the adrenergic surge from reversal. The patient will have worsening agitation with severe tachycardia.

The patient was diaphoretic and out of control. They couldn’t get a blood pressure reading or IV access. They weren’t even able to get a pulse ox. All they knew was that he was tachycardic with a peripheral pulse of about 150. The patient was covered with scar tissue and they were unable to get a line, even with ultrasound. They tried to place an IO but the patient was thrash-ing around so much, they couldn’t stabilize him.

What do you give to this agitated patient? He was given two doses of IM midazolam of 5 mg without effect. All benzodiaze-pines are not created equal when you don’t have a line. Loraze-pam and diazepam are slower in onset when injected intramus-cularly. IM midazolam is water soluble and faster in onset.

Should the patient get haloperidol? The patient is hyperther-mic, hypertensive and tachycardic. What is the predominant toxidrome? If it is sympathomimetic, benzodiazepines are a bet-ter choice.

Could you use IM ketamine? Probably. However, this will still take 10-15 minutes to work.

IM succinylcholine? Not a good option. You don’t know if the patient is hyperkalemic or in rhabdomyolysis. You don’t know how long it will take you to achieve intubating conditions. The last thing you need is a hypoxic patient that is going down (e.g. paralysis) slowly. This patient will need rapid sequence intuba-tion. Rocuronium is preferred, probably at the upper dose rang-es (greater than 1.2 mg/kg).

An intraosseous line was placed. The patient received etomi-date and rocuronium. He was intubated and sedated. Rectal temperature was 38C. The monitor showed sinus tachycardia in the 170s and a blood pressure of 150 systolic. The patient was given IV fluids and propofol.

The patient needs to be evaluated for trauma. Do a FAST exam. Does he have free fluid anywhere? Look at his pupils. They were midrange and reactive. Look for evidence of anticholinergic tox-icity, such as enormous minimally reactive pupils.

The differential diagnosis. This could be intracranial hemor-rhage. The CT was negative. Should you pan scan? This would vary depending on the institution. This patient was managed with serial FAST exams and hemoglobin levels.

Chest x-ray was negative.

They considered the differential diagnosis of the hot and both-ered (e.g. agitated) patient; withdrawal, structural problems, metabolic, NMS and serotonin syndrome, thyrotoxicosis, sep-sis and meningitis. The toxicology screen came back positive for benzodiazepines (given in the ED), amphetamine, PCP, opioids and cocaine. Cultures were drawn and the patient was covered with meningitis doses of ceftriaxone and vancomycin.

Should you send an acetaminophen and salicylate level? Yes. Salicylate overdose can present similarly with hyperthermia and agitation. Aspirin and acetaminophen levels were negative.

Consider thyrotoxicosis. Check a TSH.

Could this be neuroleptic malignant syndrome or serotonin syndrome? It can be difficult to differentiate between these two conditions, especially in an intubated, sedated patient who is unable to provide any medication history. Some findings may suggest one over the other. Lower extremity rigidity greater than upper extremity rigidity and agitation are more suggestive of serotonin syndrome. Lead pipe rigidity is more suggestive of neuroleptic malignant syndrome. Would you empirically give dantrolene, bromocriptine or cyproheptadine? Probably not.

Could this be environmental exposure? The temperature would probably be higher.

Could this be alcohol withdrawal? Yes, but there was no associ-ated tremor.

Don’t anchor on a diagnosis. It is probably a sympathomimetic overdose. However, you need to consider other etiologies, as well as associated rhabdomyolysis. It isn’t a bad idea to recheck the CK if the patient will be in the emergency department for some time.

CASE A 20 year old man was brought to the emergency department by paramedics. They found him with presumed heroin over-dose. He was not breathing. He was noted to have track marks all over his arms. EMS administered a large amount of nalox-one. He was given 2 mg intranasally. Initially it seemed to work. He was given an additional two doses of 2 mg IM.

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From The MailbagRob Orman MD and Anand Swaminathan MD The easy IJ. When should we use it? When should we not? One

of the main exclusion criteria in the study discussed on EMRAP was hemodynamic instability. Patients had to be able to dilate their IJ with Valsalva. If your patient needs a central line, place it and save this procedure for the patient that is stable but needs a line for hydration or antibiotics and does not have access other than a central line or IO. Many of the patients in the study were discharged home from the ED.

Regarding double dose doxycycline for community acquired pneumonia, Ian L. writes that doxycycline should be taken while the patient is sitting and with water. There is a danger of esophagitis without doing this. GI side effects and photosensi-tivity will be even more of a problem with a double dose.

Elizabeth P. writes in regarding the segment on abdominal pain in the elderly; “You mentioned measuring the aorta in both transverse and longitudinal direction. This is not correct. You only measure the aorta in the transverse. Measuring in the longitudinal direction is not a good idea as your probe may slide off to one side of the aorta, especially if it is large in diameter. If your probe is not directly in the center, you may measure the diameter on the side of the aorta giving a falsely low diameter. While it is important to view the entire aorta in the longitudinal direction to look for dissection flaps or saccular aneurysms, it is not the proper way to measure it.”

However, the ACEP policy statement still recommends mea-suring the maximum aortic diameter in both the transverse and longitudinal planes. This problem can also occur in the transverse plane if the probe is placed at an angle on the aorta. Therefore it is best to measure in both planes to verify measurement is consistent.