Topics in this EM Quick Hits podcast

Anand Swaminathan on priorities in massive pulmonary embolism management (0:54)

Michelle Klaiman on gabapentin for alcohol withdrawal (7:31)

Hans Rosenberg on management of dental avulsions (13:47)

Anna MacDonald on approach to the pediatric eye exam (19:00)

Justin Morgenstern on normal saline vs balanced fluids (26:45)

Podcast production, editing and sound design by Anton Helman

Podcast content, written summary & blog post by Anand Swaminathan, Michelle Klaiman, Hans Rosenberg, Anna MacDonald & Justin Morgenstern, edited by Anton Helman, January 2019

Cite this podcast as: Helman, A. Swaminathan, A. Klaiman, M. Rosenberg, H. MacDonald A, Morgenstern J. EM Quick Hits 1 – Massive PE, Gabapentin for Alcohol Withdrawal, Dental Avulsions, Pediatric Eye Exam, Best Resuscitation Fluid. Emergency Medicine Cases. January, 2019. [date].

Priorities in massive pulmonary embolism management

  1. Massive PE is a true life threat. These patients will die and will die quickly if you don’t act; so get moving.
  2. You don’t need a CT to pull the trigger on treatment – think about what else could cause the clinical scenario and master POCUS to quickly eliminate these causes and gain supporting evidence of PE (see Rob Simard’s video POCUS Cases 1 – POCUS for PE)
  3. If the patient has PE with hemodynamic compromise or collapse, consider thrombolytics but don’t forget the other things; start a vasopressor for hemodynamic support and avoid fluids whenever possible.
  4. We don’t know the right dose of lytics so tailor to the patient in front of you. If the patient is in cardiac arrest, use 50mg alteplase or tenecteplase as an initial dose.

REBEL EM: The Critical Pulmonary Embolism Patient

PulmCrit: Controlled Thrombolysis of Submassive PE

Wan S et al. Thrombolysis compared with heparin for the initial treatment of pulmonary embolism: a meta-analysis of the randomized controlled trials. Circulation 2004; 110(6): 744-9.

Wang C et al. Efficacy and safety of low dose recombinant tissue-type plasminogen activator for the treatment of acute pulmonary thromboembolism: a randomized, multi center, controlled trial. Chest 2010; 137(2): 254-62.

Gabapentin for alcohol withdrawal

  1. Benzodiazepines are first line therapy for acute alcohol withdrawal in the ED (deep dive on Episode 87 Alcohol Withdrawal and Delirium Tremens).
  2. Once patients are loaded with benzodiazepines and withdrawal symptoms are controlled, no outpatient prescription for benzodiazepines is required.
  3. Gabapentin is at least as effective as lorazepam for acute alcohol withdrawal, but there is not enough data to support its use as monotherapy.
  4. Rather than providing an outpatient prescription for benzodiazepines, consider gabapentin 300-400mg tid X 4-7 days then taper for subacute alcohol withdrawal. Tell patients to skip a dose if they feel too sedated.

Leung JG et al. The role of gabapentin in the management of alcohol withdrawal and dependence. Ann Pharmacother. 2015 Aug;49(8):897-906. Epub 2015 May 12. Review

Malcolm R, Myrick H, Roberts J, Wang W, Anton RF, Ballanger JC. The effects of carbamazepine and lorazepam on single versus multiple previous alcohol withdrawals in an outpatient randomized trial. J Gen Intern Med. 2002;5:349–355.

Munice HL Jr, Yasinian Y, Oge’ L. Outpatient manamgnemt of alcohol withdrawal syndrome. Am Fam Physician. 2013;88:589.

Myrick H et al. A double-blind trial of gabapentin versus lorazepam in the treatment of alcohol withdrawal. Alcohol Clin Exp Res 2009 Sep; 33:1582.

Poulos CX, Zack M. Low-dose diazepam primes motivation for alcohol and alcohol-related semantic networks in problem drinkers. Behavioural Pharmacolgy. 2004;14:503–512.

ED management of dental avulsions

  1. Place the avulsed tooth in appropriate transport media as soon as possible; readily available media includes: milk, saline and saliva.
  2. Extra-oral dry time of greater than about 60 minutes will lead to an unsalvageable tooth.
  3. Take great care not to damage or handle the periodontal ligament while replacing the tooth in the socket.
  4. Use 2-octyl cyanoacrylate (dermabond, swiftset) with a nasal bridge of an N95 mask as a splint if you do not have Coe-Pak in your ED.

Steps using 2-OCA and N95 mask nasal bridge:

  1. Rinse the tooth with saline.
  2. Rinse the socket with saline and then pat dry with a surgical sponge.
  3. Reimplant tooth into the socket.
  4. Ensure the tooth is dry before applying 2-octyl cyanoacrylate (2-OCA) to the lateral edges of the tooth so that the glue sticks to the adjacent teeth.
  5. Secure the avulsed tooth by applying 2-OCA to the N95 mask nasal bridge cut to size, and then to the avulsed tooth as well as the adjacent teeth on either side.  Ensure that the edges of the nasal bridge are smooth.
  6. Hold the splint under pressure for 30 seconds.

dental avulsion

Splint for dental avulsion using 2-OCA and nasal bridge from N95 mask

Rosenberg H, Hickey M. Emergency management of a traumatic tooth avulsion. Ann Emerg Med. 2011;57(4):375–377. doi:10.1016/j.annemergmed.2010.06.004.

DiAngelis AJ, Andreasen JO, Ebeleseder KA, et al. International Association of Dental Traumatology guidelines for the management of traumatic dental injuries: 1. Fractures and luxations of permanent teeth. Dent Traumatol. 2012;28(1):2–12. doi:10.1111/j.1600-9657.2011.01103.x.

Pediatric eye exam tips and tricks

  1. Get and keep their attention; the smartphone is your friend
  2. Just watch them – general observation gives you a lot of info
  3. Tetracaine eye drop trick for kids with pain who refuse to open their eye – make a puddle of drops in the inner corner of the eye, when they open or blink the drops will distribute naturally across the eye
  4. If they are too little to use the paediatric Snellen chart see if they can fix and follow. If they can’t, then see if they can blink to light.
  5. While they are fixated on the toy or phone, check:
    1. Pupillary responses
    2. Alignment (can use cover-uncover test)
    3. Visual fields (use a second toy in their peripheral field to see if they notice it)
  6. The ophthalmoscope is useful for:
    1. Red reflex
    2. Substitute for a slit lamp
    3. Fundoscopy
  7. If you still can’t get a good enough exam consider ocular ultrasound or sedation.

The Evidence for Normal Saline vs Balanced IV Fluid

  1. SALT-ED was large single center observational trial of 13,000 ED patients admitted to non-ICU beds that showed no mortality difference between normal saline and either Ringer’s lactate or Plasmalyte (full critical appraisal of SALT-ED)
  2. SMART was another large observational trial of 15,000 ED patients from the same single center admitted to the ICU compared normal saline to Ringer’s lactate or Plasmalyte for a composite outcome of death, dialysis and a 200% increase in creatinine, with the balanced fluid showing a 1% absolute benefit but with questionable statistic significance (full critical appraisal of SMART)
  3. SPLIT was a large multicenter double blind crossover RCT showing no difference in renal failure between normal saline and balanced fluid (full critical appraisal of SPLIT)
  4. Normal saline is safe to use as the initial resuscitation fluid but may worsen acidosis in large doses, so best to avoid it in known acidotic patients who require large amounts of fluid
  5. Balanced fluids are also reasonable to use but beware of the package insert incompatibility between Ringer’s Lactate and piperacillin-tazobactam, tranexamic acid and some blood products that might slow down your team
  6. Stick with a fluid that your entire team is familiar with to avoid mistakes and tailor your fluid choice to the individual patient by considering whether or not they are acidotic, the volume of fluid required and how familiar your team is with balanced fluids

Self WH, Semler MW, Wanderer JP, et al. Balanced Crystalloids versus Saline in Noncritically Ill Adults. The New England journal of medicine. 2018; 378(9):819-828.

Semler MW, Self WH, Wanderer JP, et al. Balanced Crystalloids versus Saline in Critically Ill Adults. The New England journal of medicine. 2018; 378(9):829-839.

Young P, Bailey M, Beasley R, et al. Effect of a Buffered Crystalloid Solution vs Saline on Acute Kidney Injury Among Patients in the Intensive Care Unit: The SPLIT Randomized Clinical Trial.JAMA. 2015; 314(16):1701-10.

None of the authors have any conflicts of interest to declare