Abdominal CPR?

There was a case report published in the Western Journal of Emergency Medicine last year about interposed abdominal compression CPR (IAC-CPR).  Personally, I’ve never heard anything of the sort and had to take a deeper look into it.  Essentially, you need two people to do compressions, one for the chest and one for the abdomen.  The abdominal compressor performs CPR with their hands about 5cm above the umbilicus and compressing about as deep as you would need to palpate the abdominal aorta pulse.  Both compress at the same rate and alternate their compressions; chest-abdomen-chest-abdomen and so on.  Theoretically, the abdominal compressor is acting as an external intra-aortic balloon pump.  By compressing the aorta during diastole, there is retrograde blood flow back into the coronaries.  Additionally, this abdominal compression increases venous return and promotes forward flow of the intrathoracic blood pool.  There have been no intra-abdominal injuries noted in survivors besides one pediatric traumatic pancreatitis reported in 1984.  The most recent review of IAC-CPR in Resuscitation showed significant improvements in the probability of achieving ROSC in the pre-hospital and in-hospital cardiac arrests when compared to standard CPR.  The question for me is why are we not doing this more? Is there harm in trying it if the person is already in cardiac arrest?

Post by: Terrance McGovern DO, MPH (@drtmcg13)

When kids eat coins

Kids eat up your money in more ways than one.  Some may eat it up in the form of $50,000 a year in college tuition and some eat it up as a meal.  For coins that get stuck in the esophagus the American Society for Gastrointestinal Endoscopy recommends watching asymptomatic patients for a period of 24 hours prior to any intervention.  Once the coins passes into the stomach most will traverse the GI tract without any complication.  There are multiple different methods of retrieving coins that are lodged in the esophagus: endoscopy, foley catheter technique, glucagon and bougienage is a method of pushing the coin into the stomach.  Classically, you use a Hurst dilator (or build your own) and advance it down the child’s esophagus to push the coin past the lower esophageal sphincter (step-by-step instructions).  Bougienage, when used on appropriate patients, is a safe modality for treating esophageal coins with only minor complications reported.  Some have reported success rates as high as 95%; however, you have to stick to the following inclusion criteria:

  1. Witnessed ingestion
  2. Foreign body is a coin
  3. Coin is seen in the esophagus on x-ray
  4. Single coin is present
  5. Ingestion < 24 hrs
  6. No previous esophagus procedure or pathology
  7. No respiratory symptoms
  8. Performed by trained personnel

If you successfully get the coin to pass into the stomach then the patient can be discharged home.  If the piggy bank doesn’t give up the coin in the next 2 weeks, then the patient will need a repeat xray to see where it is.  Check out this ACEP Now article for a more detailed discussion of bougienage.

Post by: Terrance McGovern DO, MPH (@drtmcg13)

 

Top 10 Infectious Disease Updates

I recently gave an “ID Updates” lecture at AAEM’s Scientific Assembly in Las Vegas, February 2016. Here are the top 10 pearls from my lecture. Some may be review, some more cutting edge. Enjoy!

  1. Use ultrasound to help guide diagnosis and management of suspected skin and soft tissue abscesses

The literature is mixed on this one but it makes sense to use ultrasound. Ultrasound seems to increase your diagnostic sensitivity and may affect management, especially in those “gray zone cases”. If you are feeling ambitious, use ultrasound after I & D to assess the success of your I & D. Plus, it’s pretty easy to do!

Alsaawi, A et al. European Journal of EM. 2016.

 

  1. Although guidelines still recommend solely I & D as the treatment of choice for simple skin and soft tissue abscesses, maybe antibiotics are not so bad!

A recent trial from Talan et al. from NEJM supports the use of antibiotics in skin and soft tissue abscesses. Antibiotics increased clinical cure and decreased complications. The knock on this trial is the included patients would have received antibiotics anyway based on disease severity; nonetheless, antibiotics benefitted patients with little harm.

Talan D et al. New England Journal of Medicine. 2016.

 

  1. First line treatment for suspected sexually transmitted infections (cervicitis, urethritis) is dual therapy Ceftriaxone 250 mg IM and Azithromycin 1 gram po.

Cefixime used to be a first line alternative (instead of Ceftriaxone), however, it is no longer with increasing resistance patterns. Bottom line—give dual therapy! Consider challenging patients who have a PCN allergy with Ceftriaxone. If you’re not going to give dual therapy with Ceftriaxone/Azithromycin, the reason better be good!

www.cdc.gov

 

  1. Newest GI recommendations state that antibiotics probably do not reduce symptom duration for uncomplicated CT proven diverticulitis.

Yes, I said it—no antibiotics for acute uncomplicated diverticulitis! Certainly, we would like to see more literature in this area, but the literature we do have show antibiotics do not improve symptoms. Antibiotics may however decrease complications, as per the guidelines. I’d like to see more here, but check out the references and see for yourself.

Strate L et al. Gastroenterology. 2015.

 

  1. Non-operative management of appendicitis is an option.

We’re not here yet in the U.S. but they are in Europe. In the newest Lancet study, 73% of patients who received non-operative management did not require an appendectomy out to one year. Those that failed non-operative management did not have complications of sepsis, abscess, or rupture compared to the operative group. The theory for non-operative management is not all appendicitis is an obstructive process that requires removal; some may respond to medical therapy.

Salminen P et al. JAMA. 2015.

 

  1. Timing of antibiotics does not reduce mortality from severe sepsis/septic shock.

CMS dictates we administer antibiotics within 3 hours of diagnosing severe sepsis/septic shock in the ED. It’s a core measure we need to meet. But it does not reduce mortality per a recent systematic review from Critical Care. Timing of antibiotics may be important, but antibiotic selection is probably more important.

Sterling S et al. Critical Care Medicine. 2015.

 

  1. Irrigation pressures do not matter in the management of open fractures.

In the OR, whether patients with open fractures get very low pressure, low pressure, or high pressure irrigation, re-op rates are the same!

The Flow Investigators. New England Journal of Medicine. 2015.

 

  1. Consider use of corticosteroids in inpatients with pneumonia.

Adjunctive prednisone in pneumonia reduced inpatient stay.

Angela Blum C et al. Lancet. 2015.

 

  1. It is thought that Strep sp. are the predominant organisms in cellulitis. But maybe not!

If Bactrim works as well as Clinda, Strep may not be the king organism in undifferentiated skin and soft tissue infections. Check out the reference.

Miller L et al. New England Journal of Medicine. 2015.

 

  1. Respect lactate!

We know lactate is not specific. But in the setting of infection or suspected sepsis, respect it if it is positive, even if in the intermediate range. Intermediate level lactates had a 30 day mortality of 15%.

Singh M et al. Annals of EM. In Press.

Post by: Nilesh Patel, DO (@nnpatel1291

Stressed vs unstressed volume

Dr. Rory Spiegel, from EMNerd, wrote a recent piece in Clinical and Experimental Emergency Medicine about how our undying love for left ventricular function in shock patients is perhaps overdoing it and the focus should rather be on the venous return. In the 1950’s Guyton et al described the three factors that affect venous return: 1. Right atrial pressure 2. Mean systemic pressure (Pms) 3. Vascular resistance.

The Pms is something that we don’t refer to often in critical care, but as Spiegel argues, should receive more respect than it does. In simple terms, Pms provides the pressure needed to produce a gradient from the venous return into the right atrium for forward flow. Spiegel provides a great analogy using a bathtub and bucket model to explain the physiology, but I’m going to attempt another analogy using a water balloon.

The Pms is composed of the blood within the venous system and the pressure exerted by the vascular bed. In the water balloon analogy, the water within the balloon is the venous blood volume and the physical balloon is the vascular bed. You can imagine, there is a certain amount of water that a water balloon can hold before the balloon starts to expand and enlarge, this is the unstressed volume. As you fill the balloon it grows and the pressure exerted by the walls of the balloon increases, this is called the stressed volume. The stressed volume produces increased Pms and subsequently increases venous return to the right atrium. Now, think of a septic shock patient as an old, ratty balloon that has been inflated too many times and has lost of lot of its elasticity. The amount of water needed in these septic balloons to get to a stressed volume is much more than a normal, healthy, brand-new balloon. Hence why we start with multiple liters of fluid resuscitation in septic shock patients, to try to get them to a stressed volume and improve the venous return. When this doesn’t work, we move onto vasopressors to clamp down on the vascular bed (squeeze the balloon) as another means of increasing Pms and venous return.

With summer around the corner, it’s going to be hard to ignore the similarities between helping your kid prepare for their next water balloon battle and dumping 30cc/kg of fluid into that old ratty, septic water balloon. Check out Spiegel’s piece in Clinical and Experimental Emergency Medicine for great review of mean systemic pressure and its relation to stressed and unstressed volume here.

Post by: Terrance McGovern DO, MPH (@drtmcg13)  

Top 10 Eye Emergency Pearls

  1. Always screen patient for an Afferent Pupillary Defect (APD)!
  2. A negative Seidel Test does not rule out a Globe rupture
  3. Avoid NSAIDS and aspirin in Hyphemas and Globe Rupture
  4. CT Scan of the Orbit is only 56-68% sensitive for identifying a Globe Rupture, so don’t solely rely on it for the diagnosis!
  5. Order a Sickle Cell Protein Hemoglobin Electrophoresis test for every patient that is African American and presents with a traumatic hyphema.
  6. Avoid Topical Pain control, such as Tetracaine 0.5%, in Hyphemas
  7. Avoid Carbonic Anhydrase Inhibitors such as Acetazolamide in Sickle Cell patients with hyphema
  8. Retrobulbar Hematoma is a clinical Diagnosis: If IOP > 40mmHg, proptosis and APD, then immediately treat! Do not wait for CT scan!
  9. In, Acute Angle Closure Glaucoma, pupil must be mid-dilated!
  10. If no APD, then it cannot be Central Retinal Artery Occlusion!

Post by: Yenis Paez-Perez, DO

The Clinical Utility of BNP in Acute CHF

ER physicians diagnose CHF often and actually very well on clinical grounds at the bedside.  So why are we ordering BNP’s when we already know the diagnosis?  The evidence clearly states in which situations the BNP will not help you.  Check out the proposed algorithm recently published in EM Resident and let’s put the evidence into real practice.

Post by: Joe Bove, DO ( @jjbove08 )