Conference Notes 11-26-2013

Happy Thanksgiving to everyone!  Feast on this week's EM discussions. 

Steffenson     Status Asthmaticus

This year has seen a record high number of intubations for pediatric asthma at ACMC.  All clinicians need to treat asthma patients aggressively to avoid having to intubate them. 

Use a Pediatric Asthma Score to assess & trend patients during their ED stay.   Respiratory therapists will calculate the Woods Asthma Score on patients in the ED.


Woods Pediatric Asthma Score   If after initial treatment in the ED, the patient's score is more than 4 probably you should be considering an ICU admission. 

No benefit of xopenex over albuterol for status asthmaticus.  There incidence of adverse effects is not lessened with xopenex.    If you are getting too much tachycardia with albuterol, you can cut back the dose instead of switching to xopenex. 

D5.9NS with 20K is recommended for maintenance fluid in status asthmaticus.   Kids tend to be alittle volume depleted in status asthmaticus so maintenance fluids are usually indicated.  

Give atrovent Q2 hours for moderate and severe asthma.   It has been shown to decrease ICU admissions.  Elise comment: how long?  Response: Give atrovent Q2 hours until patient is off continuous med neb treatments.

Steroid dose should be  2mg/kg first dose either oral or IV.

Non-Invasive Ventillation should be strongly considered early for severe asthma.   It decreases muscle fatigue and it keeps alveoli and small airways open.   Harwood question: Can we give heliox through the bipap machine?  Response: yes

Magnesium IV 50mg/kg over 30 min.  (2gm max)  Can give Q6 hr doses or give 20mg/kg/hr drip.   Goal is serum mag level of 3-5.5.

Terbutaline  IV infusion is a second line therapy.

In the PICU, aminophylline is used if a kid is heading toward intubation.   The safety profile is better for kid than adults when using aminophylline.   Probably not a drug we will be using in the ED unless a status asthmaticus patient is in the ED for a prolonged time.

Elise question: How ‘bout using epi?  Response: Optimizing the other treatments mentioned above are probably preferred choices.  Especially giving more albuterol. 

If you have to intubate,  ketamine as a sedative may give you some added bronchodilation. 

In intubated patients, inhaled anesthetics can give smooth muscle relaxation resulting in bronchodilation. 

ECMO can be lifesaving as a last ditch modality.  83% of kids placed on ECMO survive.

Harwood question: Why do you guys get troponins in these patients.   Response: If the troponin is elevated we will stop terbutaline.  We would also more strongly consider intubation.

Frazer      U/S Guided Peripheral Nerve Block

Peripheral nerve blocks have the advantage of Giving  pain relief without the side effects, time, and monitoring that go along with procedural sedation.

Interscalene brachial plexus nerve block:   Can give anesthesia to upper arm, humerus, and elbow.  Position patient like you would for an IJ line.   Put U/S probe more laterally on the neck to identify the group of 3 nerve bundles (hypoechoic or honeycomb appearance on U/S).  Depth of needle puncture is similar to the IJ approach.  Inject 15-25ml of local anesthetic.    Elise question:  What can go horribly wrong with this procedure?    Response: Hematoma, pneumothorax, paralyzed diaphragm, carotid puncture.   Harwood comment:  Phrenic nerve comes off higher than the interscalene nerves but if you go high in the neck to avoid a pneumothorax you could accidentally anesthetize the phrenic nerve.

Femoral nerve block: This block provides anesthesia to anterior thigh, femur, and knee.  Position patient as you would for a femoral  line.   Using U/S you identify the the hyperechoic or honeycomb appearing nerve lateral to femoral artery.  Orient the needle in a lateral to medial direction and inject 25ml of local anesthetic  around the nerve.   There is a risk of hematoma and infection.       Harwood comment: Most studies used a technique where you had to deposit the local anesthetic underneath the inguinal ligament.   Harwood and Elise comment: Use bupivicaine with epinepherine to give longer duration of action for your peripheral nerve blocks.

Elise comments:    Excellent discussion about nerve blocks by Erin today.  I was thinking about the "3 in 1" nerve block when I referred to a more complete nerve block to help with more proximal hip fractures/hip dislocations.  By using a larger volume of anesthetic, and as Harwood mentioned, using some distal pressure to keep the anesthetic localized proximally, you can knock out the femoral nerve as well as the lateral femoral cutaneous nerve and obturator nerve.  Obturator nerve is important for prox. hip fractures/dislocations, and using larger volumes of anesthetic helps increase your chances of anesthetizing all 3 nerves.   Remember max dose of bupivicaine with epi is 3 mg/kg or 225 mg.  You shouldn't get in trouble if you use the 0.25% bupivicaine concentration.

From the web: 

Differences between Femoral Nerve Block and 3-in-1 Nerve Block

There are two main differences.

1. Volume of local anesthetic. For femoral nerve blocks, the volume of local anesthetic is generally 20 ml or less. For 3-in-1 nerve blocks, the volume of local anesthetic is 25-30 ml. This allows the local anesthetic to spread further in the tissue plane resulting in blockade of the femoral, lateral femoral cutaneous, and obturator nerve.

2. Slight alteration in technique. Once the needle has been placed in the correct area, pressure should be applied 2-4 cm below the injection site. Next, administer the local anesthetic. Applying distal pressure helps spread the local anesthetic to the obturator and lateral femoral cutaneous nerve, in addition to the femoral nerve.


Harwood provided reference: 

A comparison of ultrasound-guided three-in-one femoral nerve block versus parenteral opioids alone for analgesia in emergency department patients with hip fractures: a randomized controlled trial.

Beaudoin FLHaran JPLiebmann O.


Department of Emergency Medicine, Rhode Island Hospital, The Alpert Medical School of Brown University, Providence, RI, USA.



The primary objective was to compare the efficacy of ultrasound (US)-guided three-in-one femoral nerve blocks to standard treatment with parenteral opioids for pain control in elderly patients with hip fractures in the emergency department (ED).


A randomized controlled trial was conducted at a large urban academic ED over an 18-month period. A convenience sample of older adults (age ≥ 55 years) with confirmed hip fractures and moderate to severe pain (numeric rating score ≥ 5) were randomized to one of two treatment arms: US-guided three-in-one femoral nerve block plus morphine (FNB group) or standard care, consisting of placebo (sham injection) plus morphine (SC group). Intravenous (IV) morphine was prescribed and dosed at the discretion of the treating physician; physicians were advised to target a 50% reduction in pain or per-patient request. The primary outcome measure of pain relief, or pain intensity reduction, was derived using the 11-point numerical rating scale (NRS) and calculated as the summed pain-intensity difference (SPID) over 4 hours. Secondary outcome measures included the amount of rescue analgesia and occurrence of adverse events (respiratory depression, hypotension, nausea, or vomiting). Outcome measures were compared between groups using analysis of variance for continuous variables and Fisher's exact test for categorical data.


Thirty-six patients (18 in each arm) completed the study. There was no difference between treatment groups with respect to age, sex, fracture type, vital signs (baseline and at 4 hours), ED length of stay (LOS), pre-enrollment analgesia, or baseline pain intensity. In comparing pain intensity at the end of the study period, NRS scores at 4 hours were significantly lower in the FNB group (p < 0.001). Over the 4-hour study period, patients in the FNB group experienced significantly greater overall pain relief than those in the SC group, with a median SPID of 11.0 (interquartile range [IQR] = 4.0 to 21.8) in the FNB group versus 4.0 (IQR = -2.0 to 5.8) in the SC group (p = 0.001). No patient in the SC group achieved a clinically significant reduction in pain. Moreover, patients in the SC group received significantly more IV morphine than those in the FNB group (5.0 mg, IQR = 2.0 to 8.4 mg vs. 0.0 mg, IQR = 0.0 to 1.5 mg; p = 0.028). There was no difference in adverse events between groups.


Ultrasound-guided femoral nerve block as an adjunct to SC resulted in 1) significantly reduced pain intensity over 4 hours, 2) decreased amount of rescue analgesia, and 3) no appreciable difference in adverse events when compared with SC alone. Furthermore, standard pain management with parenteral opioids alone provided ineffective pain control in our study cohort of patients with severe pain from their hip fractures. Regional anesthesia has a role in the ED, and US-guided femoral nerve blocks for pain management in older adults with hip fractures should routinely be considered, particularly in cases of refractory or severe pain


Kmetuck               Diarrhea 

Sorry, I missed part of this excellent lecture

Treatment for Giaridia is metronidazole

Case: 83 yo male presents as a Code 44 with 3 days of profuse watery diarrhea.   No fever, no blood in stool.   Pt is on Coumadin for afib.   Pt is curled up in bed with abdominal pain.  He appears dehydrated.   Vitals were ok: 135/98  HR 55.     Labs showed Na=147 and HCO3 =17.    CT Abdomen showed sigmoid tumor with a perforation of the sigmoid.   Pt progressed to gram negative sepsis in the ICU.   Just an example of how diarrhea can be a sign of more serious non-infectious disease process.

Non-Infectious causes of diarrhea:  Pancreatitis, crohn’s, food intolerance, thyroid disorders,  gi surgery and short gut, tumors, immunosuppression, reduced blood flow to bowel (mesenteric ischemia). 

85% of diarrhea is infectious, majority of infections are viral. 

Stool testing is indicated for severe abdominal pain, fever, bloody diarrhea,  diarrhea lasting several days.

Purnell       Head Trauma

Case: Teenage male with multiple head injuries during sporting event.  Patient had transient loc.  Patient was taken out of event for 20 minutes.  He then asked to return to play.  He passed out while he was going back on to the playing field.     On arrival to ER patient was intubated.    Be sure you get a neuro exam before you start RSI.  It is critical for neurosurgical decision making.    Initial GCS was 5.  Left pupil was dilated.   Neurosurgery was called while preparing to intubate.    Succinylcholine is considered safe in the setting of head injury.   If your brain can’t handle the ICP increase from succ you probably are not going to make it.  Omi comment: Succinylcholine ICP increase is similar to coughing.   The risk is probably not clinically relevant.  Herrmann comment: Neurosurgery doesn’t like non-depolarizing neuromuscular  blockers due to the length of paralysis thus limiting the neuro exam.  Omi comment: Lidocaine does not improve outcome when used as a modality to blunt ICP rise.   Elise comment:  Good sedation is the best way to blunt ICP rise.  Be careful with the BP though to avoid hypotension.    

There was a robust discussion between Trauma and ED faculty about the risk of iatrogenic worsening C-spine injury during intubation.   General consensus was to use video laryngoscopy preferentially over direct laryngoscopy  with either c-collar in place on patient  or using manual cspine stabilization by an assistant.  There was also agreement that the movement of the cspine produced by intubation is very unlikely to worsen c-spine trauma.  These patients have already suffered massive forces to the neck and the amount of force we apply to the spine/cord is very small in comparison.   There was a Merlotti Pearl invoked that most c-spine injuries are unstable in flexion and stable in extension (this holds true mostly for rapid deceleration  mvc’s).  Consequently, some extension during intubation is likely not a risk in the majority of patients. 

This patient in this case had a subdural and midline shift on the CT head.   There was some thought that patient had Double Impact Syndrome.  2 hits to the head in short duration can cause diffuse cerebral edema and high ICP rise.   This syndrome has 50% mortality and  the other 50% usually have severe neurologic sequelae.    Omi comment:  Also have to consider blunt neurovascular injury or diffuse axonal injury in this case.

ER docs next job is to increase cerebral blood flow and decrease ICP.   Get cerebral perfusion pressure to 50-70 and keep ICP <20.   This works out to getting the MAP to 70-90.   So give fluids to increase MAP.  Omi comment: Using pressors to increase MAP wil increase risk of ARDS, so avoid using pressors.   To reduce ICP give mannitol 1g/kg Q6 hours.   Give in push doses, don’t give as drip due to risk of accumulation and increased mortality.   Hypertonic saline may be as effective as mannitol with less rebound ICP increase later.  Elise comment: There was a recent RCT that was halted due to futility in head injured patients who received hypertonic saline.  So I am pushing back on the statement that the use of hypertonic saline in head injured patients is favored over mannitol.  Omi comment: You can’t use mannitol in dialysis patients because patients have to be able to void.   Both mannitol and hypertonic saline can have utility in particular patients.  The patient’s response to either mannitol or hypertonic saline can be prognostic.  If they don’t improve with mannitol or hypertonic saline,  they likely won’t get  better with surgery either.   Hyperventilation to 30-35 is a last resort for lowering ICP.   Omi comment: Try to avoid hyperventilation.

Keep PO2 around 200.  40% FIO2 on ventilator will usually get you there.   Transfuse if HGB <7 or if patient is hemorrhaging from another injury.   Prophylax with phenytoin or valproic acid for 7 days.   Omi comment: Phenytoin loads in elderly patients can be problematic and cause altered mental status, hypotension and arrhythmias.  There has been some research in using keppra instead of dilantin in head injured patients.  There is no current data at this time to favor keppra over Dilantin.   Keep blood sugar less than 180.  No steroid use in head injury.  Hypothermia is being studied in ongoing trials but is not recommended currently.  Raise the head of the bed 30 degrees.   There was concern about possible spinal injury and raising the head of the bed.  Omi comment: if patient is posturing with all 4 extremities they don’t have a cord injury.  It is unlikely that raising the head of the bed 30 degrees will adversely affect a cspine injury.

Desmond/White              Cultural Competence Diversity Awareness  

A cultural competency self assessment quiz was administered.

We are a product of our own cultural conditioning.

We have conscious and unconscious responses to others.

Johari Window

Cultural competence has 3 components: Manage our prejudices,  communicate across cultures, understand specific cultural populations.

 During this decade 85% of new workers will be women, non-whites and immigrants.  Newly insured patients  are more likely to be non-white, single, non-english speaking, not college educated,  and part-time employed.  Pt demographics have been changing across the nation.

Emotional intelligence has 4 areas:  Self awareness/self reflection (be aware of our biases) ,   emotional management (channel reactive energies into constructive behaviors),    Cultural competence (understanding cultural norms of other groups) reference app is available “Cultural GPS” , social awareness (intentionally structure relationships and environments to ensure they value everyone).

We make a judgment of someone in about 30 seconds.  To change your personal approach to others: ask clarifying questions, observe subtleties of the other person’s behavior, create a goal to build your multicultural awareness.   “Cultural GPS” is an app that can be useful in this regard.

Small group session worked on ways to breakdown cultural barriers between caregivers and pts/pts’ families in the ED.   Common themes where:  Be aware of internal biases, listen to patients and their families, pay attention to nonverbal cues.   Ask clarifying questions about need for interpreter services, patient’s willingness to expose their body, and which family members they prefer in the exam room. Identify who should receive info about the patient’s health, and demonstrate respect.