Topics in this EM Quick Hits podcast
Justin Morgenstern on watchful waiting for large spontaneous pneumothoraces (0:44)
Michelle Klaiman on mirco-dosing buprenorphine for opiate use disorder (5:17)
Arun Sayal on the practical application of CRITOE in pediatric elbow fractures (10:45)
Jeff Perry on The Canadian TIA Score (19:37)
Sarah Reid on updated pediatric surviving sepsis guidelines (25:59)
Salim Rezaie (Best of REBELEM) on safety of vasopressor administration through peripheral IVs (33:40)
Podcast production, editing and sound design by Anton Helman
Podcast content, written summary & blog post by Michelle Klaiman and Anton Helman
Cite this podcast as: Helman, A. Morgenstern, J. Klaiman, M. Sayal, A. Perry, J, Reid, S. Rezaie, S. EM Quick Hits 18 – Conservative Management Pneumothorax, Microdosing Buprenorphine, Practical Use of CRITOE, Canadian TIA Score, Pediatric Surviving Sepsis Guidelines, Safety of Peripheral Vasopressors. Emergency Medicine Cases. May, 2020. https://emergencymedicinecases.com/em-quick-hits-may-2020/. Accessed [date].
Watchful waiting of large spontaneous pneumothorax
- This multicenter, open label, non-inferiority trial of 316 patients compared small bore chest tube treatment for primary spontaneous pneumothorax >32% (using Collins method – see below) to conservative management (observation for 4 hours followed by repeat chest x-ray and discharge from the ED if walking comfortably and vital signs were stable)
- The primary outcome of complete radiologic resolution of the pneumothorax occurred in 98.5% of the intervention group at 8 weeks and 94.4% of the conservative management group, a “non-inferior” difference and complete resolution of symptoms at 8 weeks was similar ( 93.4% vs 94.6%)
- Secondary outcomes show that pneumothoraces took about 2 weeks longer to resolve in the conservative group, however they had shorter hospital stays, less time of work, less CT scans, less recurrence and less serious adverse events
- Consider including conservative management of spontaneous pneumothorax in shared decision making
The Collins method estimates the size of pneumothorax using a calculation based on measuring the interpleural distance at the apex (A) and the midpoints of the upper (B) and lower (C) halves of the collapsed lung to the hemithorax on a PA chest x-ray.
- Brown SGA, Ball EL, Perrin K, et al. Conservative versus Interventional Treatment for Spontaneous Pneumothorax. The New England journal of medicine. 2020; 382(5):405-415
- First10EM: Conservative treatment for pneumothorax
- St Emlyn’s JC: Conservative management of pneumothoraces.
- REBEL EM: Spontaneous Pneumothorax: Stand There and Do Nothing?
ED buprenorphine initiation and microdosing
- ED initiation of buprenorphine/naloxone is standard of care for opioid withdrawal
- Opioid agonist therapy, including buprenorphine/naloxone, is the only evidence-based treatment for opioid use disorder to reduce opioid overdose death and ED visits
- Buprenorphine/naloxone is a safe medication with a ceiling effect for respiratory depression, although this is attenuated by concurrent sedating agents such as alcohol or benzodiazepines.
- If given too early, buprenorphine/naloxone can precipitate withdrawal as it displaces full agonists and downregulates mu opioid receptors.
- If a patient is not yet in withdrawal, consider a home initiation with 6 X 2mg tablets or a microdosing protocol.
- Hammig R, Kemter A, Strasser J, von Bardeleben U, Gugger B, Walter M, et al. Use of microdoses for induction of buprenorphine treatment with overlapping full opioid agonist use: the Bernese method. Substance abuse and rehabilitation. 2016;7:99-105.
- Hu, Tina; Snider-Adler, Melissa; Nijmeh, Larry; Pyle, Adam. Buprenorphine/naloxone induction in a Canadian emergency department with rapid access to community-based addictions providers. CJEM ; 21(4): 492-498, 2019 Jul.
- Klaire S, Zivanovic R, Barbic SP, Sandhu R, Mathew N, Azar P. Rapid micro-induction of buprenorphine/naloxone for opioid use disorder in an inpatient setting: A case series. The American journal on addictions. 2019.
Using CRITOE sensibly for pediatric elbow fractures: Lateral condyle and medial epicondyle fractures
- Lateral condyle fractures comprise 15% of pediatric elbow fractures, are commonly missed in the ED and may require surgery; they are typically seen in children 3-8 years of age.
- A subtle lucency proximal to the capitellum on the elbow x-ray is either the ossification center “E” of CRITOE which closes at 10 years of age or in the 3-8 year old may represent a lateral condyle fracture, which if 1-2mm displaced, is often operative
- Medial epicondyle fractures comprise 10% of pediatric elbow fractures and are commonly missed in the ED; the mechanism is usually a valgus strain, typically in a 12-16 year old child; up to 5-10mm displacement is acceptable
- If the “I” of “CRITOE” is is difficult to identify, but “TOE” are present, suspect a medial epicondyle fracture that has migrated into the elbow joint
- When in doubt order a contralateral elbow x-ray for comparison
Marx, John A., and Peter Rosen. Rosen’s Emergency Medicine: Concepts and Clinical Practice. 8th ed. Philadelphia, PA: Elsevier/Saunders, 2014.
The Canadian TIA Score
- The Canadian TIA Score stratifies risk of subsequent stroke into low, moderate and high risk.
- Prompt emergency carotid endarterectomy (CEA) to prevent stroke has a NNT = 3 in high risk patients.
- Primary outcome was the composite of subsequent stroke or CEA ≤7 days.
- Prospectively enrolled 7,569 patients of whom 107 (1.4%) had a subsequent stroke and 74 (1.0%) CEA ≤7 days
- The Canadian TIA Score stratified the stroke/CEA ≤7days risk as: Low probability <0.2%, moderate probability 1.3%, high probability 2.6%.
- Inclusion Criteria
- Age > 18
- Diagnosed with a TIA in the ED by either the ED physician or neurologist
- Exclusion Criteria
- Patients who were diagnosed with a confirmed stroke (neurological deficit present >24 hours)
- Decreased LOC (GCS <15)
- Documented other cause for deficit which was not a TIA
- Presented >7 days following onset of most recent TIA and treated with TPA for an acute stroke.
- The Canadian TIA Score seems to accurately identify TIA patients risk for stroke/CEA ≤7 days.
- Suggested care recommendations based on Canadian TIA Score (-3 to 3 points = low risk, 4-8 points = medium risk, ≥9 points = high risk)
- Low risk – safely discharge following a careful ED assessment with elective follow-up
- Moderate risk – undergo additional testing in the ED, have antithrombotic therapy optimized, and be offered early stroke specialist follow-up
- High risk – fully investigate and manage ideally in consultation with a stroke specialist during their index ED visit
Perry, J. et al. A prospective cohort study of patients with transient ischemic attack to identify high-risk clinical characteristics. Stroke. 2014 Jan;45(1):92-100. doi: 10.1161/STROKEAHA.113.003085. Epub 2013 Nov 21.
Perry, J. et al. PL01: Prospective multicenter validation of the Canadian TIA Score for predicting subsequent stroke within seven days. CJEM, 21(S1), S5-S5. 2019. doi:10.1017/cem.2019.40
Pediatric sepsis updated guidelines 2020 bottom line recomendations
Weiss SL, Peters MJ, Alhazzani W, et al. Surviving Sepsis Campaign International Guidelines for the Management of Septic Shock and Sepsis-Associated Organ Dysfunction in Children. Pediatr Crit Care Med. 2020;21(2):e52-e106.
Safety of peripheral IV vasopressors and managing their complications (Best of REBEL EM)
In the latest systematic review on this topic the extravasation rate was about 3%, and the rate of limb ischemia and compartment syndrome was 0%.
If you are faced with an extravasation event:
- Leave the catheter in place
- Slowly aspirate as much of the drug as possible
- Administer phentolamine 0.1-0.2mg/kg (max 10mg) through the IV plus 5mg/ml mixed in 9mL NS subcutaneous AND a 1 inch strip of topical nitroglycerine 2% to the site of ischemia
- Remove catheter
- Elevate the affected limb to minimize swelling
- Apply warm compressess for 20 mins q6-8h for at least 24-48hrs
In patients who are critically ill and requiring vasopressor treatment, the use of peripheral IVs are relatively safe with several caveats:
- Use an antecubital fossa or more proximal IV (These are generally larger veins which allow for larger IVs (i.e. 18g)
- Do not run the infusion for >2 – 4hrs
- Use as dilute a concentration as possible
- Use as small a volume as possible
- Have an IV observation protocol
- Have an extravasation protocol
- Tian DH et al. Safety of Peripheral Administration of Vasopressor Medications: A Systematic Review. EMA 2019.
- Pancaro C et al. Risk of Major Complications After Perioperative Norepinephrine Infusion Through Peripheral Intravenous Lines in a Multicenter Study. Anesth Analg 2019.
None of the authors have any conflicts of interest to declare