Education pearls is a weekly email sent out with pearls, pitfalls and summaries of recent research on a variety of topics pertinent to emergency medicine. The programme is developed and published through The University of Maryland Department of Emergency Medicine. Each topic is summarised in a concise easy to read format, that will only take about 10 minute’s each week to read through. Educations pearls has been going since 2007 and has an extensive archive for you to browse. So what are you waiting for… Subscribe here today and get the educational pearls dropped into your inbox each week, and keep up to date with all that is happening in emergency medicine.
Check out some of the past weeks topics:
Arrhythmias in syncope
Author: Amal Mattu
17-18% of cases of syncope are attributable to arrhythmias
The greatest predictors of arrhythmias as the cause of syncope are:
a. Abnormal ECG (odds ratio 8.1)
b. History of CHF (odds ratio 5.3)
c. Age older than 65 (odds ratio 5.4)
[Sarasin, et al. Academic Emergency Medicine 2003]
Author: Adam Friedlander
As RSV season approaches, remember these key points in managing bronchiolitis:
- Diagnosis is clinical – labs and XRays will not help you, unless you want to rule out a specific alternate diagnosis. It’s all about the H&P.
- Supportive care, including bulb suction of secretions, placing the child in a position of comfort, and possibly providing humidified air, is the mainstay of treatment.
- Ribavirin, corticosteroids, and antibiotics are not indicated. Don’t use them.
- Bronchodilators have no benefit in bronchiolitis alone, and non-response to bronchodilators supports the diagnosis of bronchiolitis. If a trial does work, know what you are treating – some children with bronchiolitis may have an underlying component of reactive airway disease, and should be treated accordingly.
- Before disposition be sure that the child can tolerate PO. A fussy, tachypneic child may require admission for IV hydration if they are unable to tolerate feeds – recall that infants are obligate nose breathers.
- Finally, beware the RSV bronchiolitis bounceback – the peak incidence of respiratory failure in RSV bronchiolitis is after 3-4 days of illness, when most children should be improving
- American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. Oct 2006;118(4):1774-93.
- Jartti T, Mäkelä MJ, Vanto T, Ruuskanen O. The link between bronchiolitis and asthma. Infect Dis Clin North Am. Sep 2005;19(3):667-89.
- Kellner JD, Ohlsson A, Gadomski AM, Wang EE. Efficacy of bronchodilator therapy in bronchiolitis. A meta-analysis. Arch PediatrAdolesc Med. Nov 1996;150(11):1166-72.
Pulmonary Contusion Ventilator Management
Author: Michael Winters
- Pulmonary contusion is the most common injury in blunt thoracic trauma.
- Patients with pulmonary contusion often present with hypoxia, hypercarbia and increased work of breathing.
- Importantly, patients with pulmonary contusion have a low cardiopulmonary reserve. Maintain a threshold for initiating mechanical ventilation in these patients.
- When starting mechanical ventilation, think about the following:
- Patients are at high risk of developing ARDS
- Most centres use low tidal volume ventilatory strategy
- High levels of PEEP may be necessary to recruit collapsed alveoli
- High frequency oscillatory ventilation (HFOV) and airway pressure release ventilation (APRV) are modes that are gaining in popularity for ventilating patients with pulmonary contusions.
- Kiraly, L. & Schreiber, M. Management of the crushed chest. Critical Care Medicine. (2010). 38(S): S469-S477.
Frozen Shoulder – Adhesive Capsulitis
Author: Michael Bond
- Characterised by pain and loss of motion or stiffness in the shoulder. Normally not seen below the age of 40, affects 2% of the population and diabetic patients are at increased risk.
- Due to thickening and contracture of the capsule surrounding the shoulder joint.
- Can occur after trauma to the shoulder if the shoulder is not moved early enough, but is also known to occur idiopathically.
- X-rays are only helpful to rule out other causes of the shoulder pain and are typically normal in adhesive capsulitis.
- Typically adhesive capsulitis will get better on its own over 2-3 years.
- Physiotherapy and home exercises aimed at restoring ROM can shorten the duration of pain and stiffness.
- Surgery can be done if there is no improvement with medical management and physiotherapy.
- Prevention strategies include early ROM exercises in those with shoulder injuries especially in the elderly diabetic.
Adrenaline Digital Injections:
Author: Ellen Lemkin
A recent study examined the effects of accidental digital adrenaline injection from auto-injectors. 127 cases with complete follow-up had the following effects:
- No effects were reported in 10%
- Minor effects in 77%
- Moderate effects in 13%
- Major effects in 1 case
Pharmacologic vasodilators were used in 23%. Four patients had possible digital ischaemia. All patients had complete resolution of symptoms, most within 2 hours. No patient was admitted, received hand surgery consultation, or had surgical care.
Although this speaks for the safety of digital anaesthesia using adrenaline, it underscores the importance of providing education to patients who are prescribed adrenaline auto-injectors.
Muck, AE. Bebarta, VS. Borys, DJ. & Morgan DL. (2010). Six years of Epinephrine Digital Injections: Absence of significant local or systemic effects. Annals of Emergency Medicine. 56(3), 270-274.
Singer, AJ. (2010). Accidental Digital self-injection of Epinephrine: Debunking the Myth. 56(3), 275-277.