FOAMED

Rapid Sequence Intubation (RSI) is one of the most critically important skills for an Emergency Medicine physician to be able to perform quickly and accurately. All airway management in the emergency department is performed on the unstable patient, often with unknown co-morbidities and a full stomach. In recent years, standard medication choices for induction were etomidate and succinylcholine. While other medications were proposed and tried, several were avoided for hypothetical side effects that have not borne out in recent research. Arguably, the modern combination of ketamine and rocuronium has less significant complications, and provides a superior alternative to etomidate and succinylcholine.

From the understanding of physostigmine’s mechanism of action and the above data, we would like to summarize key points and recommendations regarding the use of physostigmine.

I HAVE BECOME INFATUATED WITH THE PATIENT CARE EXPERIENCE. I believe the term “patient care experience” is a more inclusive term that describes our technical expertise while also including everything else, such as communication, department ambience, throughput, and the behavior of everyone a patient comes into contact with while in the department.

Originally published at Pediatric EM Morsels on March 6, 2015. Reposted with permission. Follow Dr. Sean M. Fox on twitter @PedEMMorsels Fortunately, the critically ill child is not as common in the Emergency Department as the critically ill adult. Unfortunately, when the critically ill child does arrive, it can be challenging to recognize him/her initially. This can lead to delays in resuscitation care. Even at the extreme point of being pulseless, children can be tricky (SeePalpation of Pulse). Then there is always the challenge that having to account for the effect that age has on normal vital signs (See Blood Pressures).  Often, though, by focusing on the Basics, we can met the challenge of detecting Pediatric Shock and act aggressively to treat it! Pediatric Shock Broadly speaking, shock is the state in which there is a failure to meet the metabolic demands of the body leading to anaerobic metabolism. (Mtaweh, 2013) Often categorized as: Hypovolemic Cardiogenic Distributive Toxin mediated – Septic Hypersensitivity reaction – Anaphylaxis Loss of sympathetic tone – Neurogenic Pediatric Shock: A Challenge The diagnosis is initially suspected based upon clinical exam. There is no lab value or “test” that defines shock. (See Lactate) Clinical Findings: Tachycardia Must account for age-adjusted values! Often children present with elevated heart rates without overt illness. Poor Capillary Refill Normal capillary refill can vary with age and is influenced by the environment. (Schriger, 1988) The initial cap refill in the ED, may artificially affected by the pre-hospital environment. Peripheral Pulse Quality Altered Mental Status Cold/Mottled Extremities Poor Urine Output Not likely useful in the initial assessment in the ED. If the patient is “hanging out” in your ED for some time, monitor this! Of these clinical findings, only Altered Mental Status and Poor Peripheral Pulse Quality was associated with development of Organ Dysfunction. (Scott, 2014) No single finding defines shock, but the absence of all of them is reassuring. Pediatric Shock: The Shock Index The Shock Index (Heart Rate / Systolic BP) has been shown to be useful in detecting adult patients with shock. There is evidence that the Shock Index can be useful in pediatric patients also. (Yasaka, 2013; Rousseaux, 2013) Since, pediatric vital signs alter with age, it would make sense to have a“adjusted” tool. (Acker, 2015) Using standard heart rate and systolic BP values for age ranges, Maximum Normal Shock Index values were calculated. Shock Index, Pediatric Adjusted (SIPA) 4-6 years = 1.2 6-12 years = 1 > 12 years = 0.9 Comparing the patient’s actual HR / Systolic BP to the SIPA was shown to perform better and identify those most severely injured following blunt trauma. (Acker, 2015) Obviously, this may not apply to all pediatric patients presenting with shock, but I do like the concept of utilizing Basic information that is age adjusted. Consider utilizing this tool as another method to help find those subtle presentations of shock.  Remain Vigilant! References Acker SN1, Ross JT2, Partrick DA3, Tong S4, Bensard DD5. Pediatric specific shock index accurately identifies severely injured children. J Pediatr Surg. 2015 Feb;50(2):331-4. PMID: 25638631. [PubMed] [Read by QxMD] Scott HF1, Donoghue AJ, Gaieski DF, Marchese RF, Mistry RD. Effectiveness of physical exam signs for early detection of critical illness in pediatric systemic inflammatory response syndrome. BMC Emerg Med. 2014 Nov 19;14:24. PMID: 25407007. [PubMed][Read by QxMD] Dellinger RP1, Levy MM, Rhodes A, Annane D, Gerlach H, Opal SM, Sevransky JE, Sprung CL, Douglas IS, Jaeschke R, Osborn TM, Nunnally ME, Townsend SR, Reinhart K, Kleinpell RM, Angus DC, Deutschman CS, Machado FR, Rubenfeld GD, Webb S, Beale RJ, Vincent JL, Moreno R; Surviving Sepsis Campaign Guidelines Committee including The Pediatric Subgroup. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med. 2013 Feb;39(2):165-228. PMID: 23361625. [PubMed] [Read by QxMD] Mtaweh H1, Trakas EV, Su E, Carcillo JA, Aneja RK. Advances in monitoring and management of shock. Pediatr Clin North Am. 2013 Jun;60(3):641-54. PMID:23639660. [PubMed] [Read by QxMD] Yasaka Y1, Khemani RG, Markovitz BP. Is shock index associated with outcome in children with sepsis/septic shock?*. Pediatr Crit Care Med. 2013 Oct;14(8):e372-9. PMID: 23962830. [PubMed] [Read by QxMD] Rousseaux J1, Grandbastien B, Dorkenoo A, Lampin ME, Leteurtre S, Leclerc F.Prognostic value of shock index in children with septic shock. Pediatr Emerg Care. 2013 Oct;29(10):1055-9. PMID: 24076606. [PubMed] [Read by QxMD] Schriger DL1, Baraff L. Defining normal capillary refill: variation with age, sex, and temperature. Ann Emerg Med. 1988 Sep;17(9):932-5. PMID: 3415066. [PubMed] [Read by QxMD]

Check out our latest in our D-List Superbugs series of rare cases caused by rare bugs. EM docs need to have these in their differential as it can cause national morbidity/mortality!

Questioning the current practice management of diverticulitis? Read about the most recent review of a large meta-analysis regarding this hot topic

Pearls and Pitfalls

Cellulitis that is associated with purulent drainage is commonly associated with Staphylococcus Aureus compared to non-purulent cellulitis that is more commonly β hemolytic streptococcus. Antimicrobial therapy should be directed at the organism in question.
Cellulitis may not appear as red and can span the gamut from pale to violet coloration in deeper infections. Pain is not always present particularly in immunocompromised patients.
Cultures from peripheral blood, needle aspirates, skin biopsies, and surgical specimens have a relatively low yield. They should be considered however in patients with purulent drainage, those who failed outpatient therapy, or immunocompromised patients.

It’s a crazy night in the ED, and you are about four hours into your shift. You have just received a new patient with chief complaint of altered mental status coming in via EMS.