<![CDATA[Emergency Medicine Education - Blog]]>Fri, 19 Sep 2014 12:50:41 -0800Weebly<![CDATA[Imaging of head injury in children]]>Fri, 15 Aug 2014 02:09:55 GMThttp://emergencyeducation.net/1/post/2014/08/imaging-of-head-injury-in-children.htmlHead injury in children is a common problem in the emergency department.
  • With moderate and severe head injury (GCS < 13/15) there is no question that child should have imaging.
  • Children with minor head injury (GCS 14-15) have a small risk of traumatic brain injury and the question arises when should you image these patients.
  • There have been numerous clinical decision rules to help us make this decision - PECARN, CATCH and CHALICE
  • A recent study has now compared the 3 major clinical decision rules head-to-head and compared them to physician estimation. This was a prosepective study involving 1009 children comparing the 4 approaches
  • The PECARN rule and physician practice are the only 2 approaches to demonstrate 100% sensitivity in this article
  • Reviewing the PECARN rule, it is divided into children under the age of 2 and those above the age of 2.
  • No CT Brain recommended in age under 2 if; normal mental status, no scalp haematoma except frontal, LOC for less than 5 seconds, non severe injury or mechanism, no palpable skull fracture, normal behaviour.
  • No CT Brain recommended in age greater than 2 if; normal mental status, no LOC, no vomiting, non severe injury or mechanism, no signs of BOS fracture, no severe headache.
  • Severe injury mechanism was defined as MVA with patient ejection, death of passenger or rollover. Pedestrian or bicyclist without helmet struck by motorized vehicle, fall greater than 1.5m for children older than 2 and fall greater than 0.9m fir children less than 2 or head struck by a high impact object.

References;


  • Kupperman N et al. Identification of children at very low risk of clinically important brain injuries after head trauma: a prospective cohort study. Lancet 2009;374;1160-70
  • Bakes K et al. Comparison of PECARN, CATCH and CHALICE rules for children with minor head injury: A prospective cohort study. Ann Emerg Med 2014;64;145-152.


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<![CDATA[Prophylactic Protective Ventilation]]>Fri, 15 Aug 2014 01:56:04 GMThttp://emergencyeducation.net/1/post/2014/08/prophylactic-protective-ventilation.htmlProphylactic Protective Ventilation
Recent evidence suggests that mechanical ventilation with high tidal volumes in critically ill patients can be harmful.
Use of lower tidal volumes such as in ARDS can also benefit patients without ARDS. Use 6-8 mL/kg in patients at risk for ARDS and 10 mL/kg for those without risk for ARDS.
Use a predicted body weight rather than actual body weight (smartphone calculators are available for this)
Moderate levels of PEEP are recommended to avoid development of atelectasis - initial levels of 8 cmH20 with subsequent titration depending on FI02 and haemodynamic status.
The authors recommend a reduction in FI02 to levels less than 60% and an initial respiratory rate of 20 or higher when tidal volumes of less than 10 ml/kg are used.

Lellouche F et al. Prophylactic protective ventilation: lower tidal volumes for all criticaly ill patients? Intens Care Med; 2013; 39(1); 6
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<![CDATA[Sub-Segmental PE - are they clinically significant?]]>Fri, 15 Aug 2014 01:51:19 GMThttp://emergencyeducation.net/1/post/2014/08/sub-segmental-pe-are-they-clinically-significant.htmlPulmonary Embolism
  • Increasing use of CTPA has resulted in an increase in the diagnosis of sub-segmental pulmonary embolism. Some have questioned the clinical significance of this finding.
  • This study showed that the mortality risk in patients with segmental or more proximal PE was 6.5% and in patients with sub-segmental PE, the mortality risk was 10.7%. This study challenges the idea that sub-segmental PE's are clinically insignificant.

Reference
den Exter PL et al. Risk profile and clinical outcome of symptomatic sub segmental acute pulmonary embolism. Blood; 2013;122(7);1144.
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<![CDATA[Primary PCI for AMI]]>Fri, 15 Aug 2014 01:50:46 GMThttp://emergencyeducation.net/1/post/2014/08/primary-pci-for-ami.htmlDoor to Balloon Time for Primary PCI
  • Benefit in the hyperacute setting - first 60 minutes
  • No benefit in mortality for more prolonged door to balloon times.

Reference
Menees DS et al. Door to Balloon time and mortality among patients undergoing primary PCI. NEJM; 2013;369(10);901
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<![CDATA[Is a CT necessary before LP?]]>Fri, 15 Aug 2014 01:47:46 GMThttp://emergencyeducation.net/1/post/2014/08/is-a-ct-necessary-before-lp.htmlMeningitis, Lumbar Puncture and CT Scanning
CT scanning is commonly performed prior to lumbar puncture to avoid the risk of cerebral herniation if raised intracranial pressure is present.
CT scanning will not necessarily demonstrate precursors to cerebral herniation, and the risk of cerebral herniation even in the presence of raised intracranial pressure is low.
Current recommendations in this Swiss paper call for immediate LP in patients with suspected meningitis except in those who are suspected to have a mass lesion (focal neurological deficit), ongoing or impending cerebral herniation, ongoing seizures, papilloedema, severe coagulopathy or treatment with anticoagulants or infection at the LP site.
If LP cannot be performed immediately, they recommend blood cultures, followed by administration of antibiotics and steroids.

Reference
Glimaker M et al. Early lumbar puncture in adult bacterial meningitis: rationale for revised guidelines. Scand J Infect Dis. 2013;45(9);657 
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<![CDATA[Updates in Paediatric Analgesia]]>Fri, 15 Aug 2014 01:44:54 GMThttp://emergencyeducation.net/1/post/2014/08/updates-in-paediatric-analgesia.htmlIntranasal Ketamine
Intranasal fentanyl has been shown to be an effective analgesic with paediatric patients with acute pain, but what about other agents?
Intranasal ketamine at a dose of about 1 mg/kg produced adequate analgesia in a small convenience sample of children with moderate to severe pain due to isolated limb injuries.
This could be a useful adjunct for non-invasive analgesia in children.

Yeaman F et al. Sub-dissociative dose intranasal ketamine for limb injury pain in children in the emergency department: A pilot study. EMA 2013; 25(2); 16
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<![CDATA[No evidence for therapeutic hypothermia in cardiac arrest patients.]]>Fri, 15 Aug 2014 01:44:23 GMThttp://emergencyeducation.net/1/post/2014/08/no-evidence-for-therapeutic-hypothermia-in-cardiac-arrest-patients.htmlTherapeutic Hypothermia?
Therapeutic hypothermia had been recommended based on 2 small positive trials.
This was a large multinational study with patients randomised to temperature targets of 36 and 33 degrees.
This study showed no benefit to cooling patients to 33 degrees compared to 36 degrees in comatose patients following cardiac arrest.

This was a well designed RCT, and it seems to show that therapeutic hypothermia is not effective. We should be aiming for normothermia and avoiding hyperthermia with cardiac arrest patients.

Nilesen N et al. Targeted temperature management at 33C versus 36C after cardiac arrest. NEJM; 2013; 369(23);2197
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<![CDATA[Fever and Antipyretic Therapy]]>Fri, 15 Aug 2014 01:42:32 GMThttp://emergencyeducation.net/1/post/2014/08/fever-and-antipyretic-therapy.htmlDoes the use of antipyretics prolong febrile illness in children?
This study was a review of 6 randomised trials of antipyretics in paediatric patients with a febrile illness.
It included patients with malaria, varicella and respiratory infections. Paracetamol was used in all but one of the trials which used ibuprofen.
Resolution of fever was faster in the antipyretic group by 4.2 hours.
There is no evidence that antipyretics prolong febrile illnesses in children.

Reference
Pursell E et al. Does the use of antipyretics in children who have acute infections prolong febrile illness? A systematic review and meta-analysis. J Paed; 2013; 163(3) 822
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<![CDATA[Statin toxicity with coadministration of macrolides.]]>Fri, 15 Aug 2014 01:39:45 GMThttp://emergencyeducation.net/1/post/2014/08/statin-toxicity-with-coadministration-of-macrolides.htmlStatin Toxicity
Atorvastatin, Simvastatin and lovastatin are all metabolised by the CYP3A4 isoenzyme. Coadministration of a CYP3A4 enzyme inhibitor such as clarithromycin or erythromycin increases the risk of statin toxicity (rhabdomyolysis,acute kidney injury and hyperkalemia). This effect is seen more predominantly in elderly patients.

Patel AM et al. Statin toxicity from macrolide antibiotic coprescription: A population-based cohort study. Ann Int Med; 2013; 158(12); 869
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<![CDATA[Metoclopramide Induced Akathisia]]>Fri, 15 Aug 2014 01:36:10 GMThttp://emergencyeducation.net/1/post/2014/08/metoclopramide-induced-akathisia.htmlMetoclopramide Induced Akathisia
Akathisia is a common side effect of metoclopramide - frequency is not decreased by slow infusion compared to bolus administration.

Egerton-Warburton D et al. Administration of metoclopramide by infusion or bolus does not affect the incidence of drug-induced akathisia. EMA; 201325(3);207
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