Droperidol, Ziprasidone or Ativan for Agitation Control in the ED

Martel ML, Driver BE, Miner JR, Biros MH, Cole JB. Randomized Double-blind Trial of Intramuscular Droperidol, Ziprasidone, and Lorazepam for Acute Undifferentiated Agitation in the Emergency Department. Acad Emerg Med. 2021 Apr;28(4):421-434. doi: 10.1111/acem.14124. Epub 2020 Oct 5. PMID: 32888340.

The answer is still Droperidol however given the small sample size this still needs to be interpreted with caution!

The authors do however state that this confirms “findings from a retrospective chart review of 4,947 patients at our institution sedated with droperidol that demonstrated a 17% rescue sedation rate”.(1) However, “a prospective study from Australia of 1,403 patients receiving droperidol for acute agitation found a higher rescue rate of 31%”.(2)

  1. Calver L, Page CB, Downes MA, et al. The safety and effectiveness of droperidol for sedation of acute behavioral disturbance in the emergency department. Ann Emerg Med 2015;66:230–8.e1. 0.1016/j.annemergmed.2015.03.016
  2. Klein LR, Driver BE, Horton G, Scharber S, Martel ML, Cole JB. Rescue sedation when treating acute agitation in the emergency department with intramuscular antipsy- chotics. J Emerg Med 2019;56:484–90.

SO YOU THINK YOU KNOW CELLULITIS?

Sometimes things aren’t as they seem.  As an attending I often hear from a resident “Hey got an easy one for ya, 50 y/o diabetic with bilateral cellulitis vanc given, I’ll get some admit labs” followed by a precipitous mic drop.

I was told once that a good attending “makes a difficult case simple and a simple case difficult” I believe that more and more these days. So is a simple case of cellulitis really that simple? Well in a study by Weng in 2016, 30% of 259 pts were misdiagnosed with cellulitis. A similar study by Li also 30 percent of 116 patients were incorrectly diagnosed as cellulitis” in a study by Li in 116 patients. Thirty percent is a large number, but does it surprise me? Not really.  I have heard so many times a patient is getting admitted for “bilateral cellulitis”.  So you are telling me there are two skin infections starting at the feet and racing to the groin like two trains approaching each other??? If you think about it kind of doesn’t make sense that this would exist much. Maybe in a very immune-compromised patient it can occur but otherwise the patient should be really sick. If I really think about it in IVDU patients with skin abscess all over even they don’t have bilateral cellulitis! In fact every case report of bilateral cellulitis I found was actually on how “bilateral cellulitis” was the WRONG diagnosis.

So if its not cellulitis then what is it (we will get back to the bilateral part in a bit)?

NECROTIZING FASCIITIS

I asked an intern what is his approach to a patient differential diagnosis. “Worst first” he said. I chuckled a bit since I appreciate alliteration. But in an overall way he is on the right track so on that note lets start off with the worst: Necrotizing fasciitis (NF). However, this will not be a lengthy discussion because there are so many good resources on NF. Instead I want to focus on some pearls for this diagnosis. To start one thing that makes me feel better is this quote in Clinical infections disease by Anaya “Establishing the diagnosis of necrotizing soft tissue infections is not easy”. Thanks for that, what no clinical correlation recommended? The typical findings of blisters/bullae, crepitus, gas, fever, tachycardia, hypotension, and shock have a low sensitivity of only 10-40%.  Well is there anything that can help us? When all else fails examine the patient. We need to see if the area is necrotic. So, one helpful trick is the “finger test”in the almost brilliantly named BMJ article “Necrotizing Fasciitis: Always used the finger” (which I would have said give them the finger but the Brits always have to be proper). Here a test incision is made in the suspected area of approximately 2 cm. A positive test would be characterized by the absence of normal blood flow, dirty’ dishwater’ colored fluid and discoloration of the fat. Then a rapid finger sweep at the level of the fascia can be carried out. If the tissues dissect with minimal resistance this again favors the diagnosis.

CELLULTIS MIMICS

TEN TIPS FOR DISTINGUISHING CELLULITIS FROM MIMICS

The simplest way to think about this would be to say there is cellulitis and then there is everything else. So what are some pearls for the diagnosis of these tricksters?

  1. Cellulitis is rarely bilateral! Fact!
    1. Corollary: Vascular dermatitis is usually bilateral
  2. Elevate the leg when you examine it! Dependent redness is often mistaken for cellulitis, but erythema promptly disappears after elevating the leg at the bedside. Dependent redness is often asymptomatic, but can be associated with rest pain from arterial insufficiency.
  3. Stasis dermatitis (AKA venous eczema) is the most common mimic of cellulitis.
  4. Superficial thrombophlebitis can appear similar to lymphangitis however DVT of the lower limb rarely causes cutaneous erythema EXCEPT in the proximal thigh, where the femoral vein lies just below the skin surface
  5. Cellulitis is not typically itchy, its painful
    1. Corollary: IF the area is insensate worry about Nec Fasc!
  6. Malignancy affecting the lymphatics of the lower extremities can closely mimic cellulitis!
  7. Failure of  antibiotics should make you think twice about the diagnosis of cellulitis
  8. Cellulitis should have inguinal lymphadenopathy
  9. Confluent Erythema Nodosum can have a similar appearance but will have a different feel since it is a panniculitis
    1. Corollary: Cellulitis should be smooth and not be made up of firm nodules!
  10. Erythema Multiform can have a similar appearance and mistaken for allergic reaction or cellulitis.

ALTERNATIVE DIAGNOSIS OF CELLULITIS MIMICS

Stasis Dermatitis (aka Venous Eczema):

  • Ill-defined, bilateral, pitting edema of the lower extremities, typically with erythema, hyperpigmentation, serous drainage, and su- perficial desquamation
  • Chronic venous insufficiency causes micro- vascular changes and microthrombi leading to acute cutaneous inflammation
  • ill-defined erythematous plaque with overlying pigment changes and super- ficial desquamation, as well as nonpitting edema

Lipodermatosclerosis

  • Necrosis, and fibrosis of the subcutaneous fat, especially in women
  • It usually develops much more slowly than cellulitis—over weeks to month
  • A sclerosing panniculitis classically described as an “inverted champagne bottle” or “inverted bowling pin” appearance of the leg, ie, the diameter of the leg is sharply narrowed directly below the calf
  • There is an acute and a chronic phase. The acute phase is characterized by inflammation and erythema, and the chronic phase is characterized by fibrosis
  • The acute phase can be difficult to differentiate from cellulitis. venous insufficiency, cutaneous changes of stasis dermatitis, and the absence of systemic symptoms all point to lipodermatosclerosis.

Contact Dermatitis

  • The lesion is a painful, nonpruritic, well-demarcated, erythematous, weeping plaque with scattered vesicles at the periphery, as well as superficial desquamation and scaling.
  • Ask about recent changes in medications, soaps, and laundry detergents, new hobbies, or recent surgeries. The involved site is often confined to the area where the allergen contacted the skin

Lymphedema

  • Localized edema of an affected extremity, with induration, erythema, and secondary cutaneous changes such as hyperkeratosis, dyspigmentation, and wart-like architecture
  • Has the patient undergone lymph node dissection? Has the patient had an injury in the affected leg? Lymphedema is overwhelmingly unilateral and nonpitting, and is often seen in overweight people

Eosinophilic cellulitis, or Wells syndrome

  • It is a recurrent hypersensitivity reaction to a drug, to a vaccine, or to an insect bite, or to a viral or fungal infection that pre- sents on the extremities as localized erythema, edema, and induration with sharp borders and a green or gray hue
  • Patients tend to report itching and burning that precedes the
  • onset of plaques the complete blood count typically shows a transient hypereosinophilia

Erythromelalgia

  • is a rare disorder that causes episodes of heat, redness, and burning discomfort provoked by heat and dependency and relieved by elevation and cooling of the extremity
  • Primary occurs more common in women than men
  • Can be a marker of systemic disease associated with: myeloproliferative neoplasms of polycythemia vera, essential thrombocythemia, and chronic myelogenous leukemia.
  • Age of onset is typically in the forties and fifties.
  • The symptoms are nearly always intermittent, with episodes usually lasting from a few minutes to a few hours, but occasionally lasting for several days
  • They are typically provoked or worsened by limb dependency, exercise, and heat and alleviated by the opposite of these

Gout

  • The onset of an attack is abrupt, causing severe pain, tenderness, erythema, swelling, and warmth over the affected joint.
  • Evolves rapidly, reaching its maximal intensity within 6 to 12 hours.
  • Commonly expands a considerable distance beyond the joint itself, producing extensive cutaneous inflammation that may strongly resemble cellulitis.
  • Fever occasionally occurs,
  • Careful examination, , usually indicates that the origin of the inflammation is clearly in the synovial space, rather than the soft tissues
  • Movement of the affected joint and pressure over it produce exquisite pain that is less intense with compressing adjacent inflamed, non- articular tissue
  • Don’t order a serum uric acid! It doesn’t help!

REFERENCES

  1. Weng QY, Raff AB, Cohen JM, Gunasekera N, et al. Costs and consequences associated with misdiagnosed lower extremity cellulitis. JAMA Dermatol.
  2. Li et al. Outcomes of Early Dermatology Consultation for Inpatients Diagnosed With Cellulitis. JAMA Dermatol. 2018 May 1;154(5):537-543.
  3. Anaya et al. Necrotizing Soft-Tissue Infection: Diagnosis and Management. Clinical Infectious Diseases, Vol. 44, No. 5 (Mar. 1, 2007), pp. 705-710
  4. Necrotizing Fasciitis: Always use the finger. BMJ 2005;330:830
  5. Lower limb cellulitis and its mimics Part II. Conditions that simulate lower limb cellulitis. J Am Acad Dermatol 2012;67:177.e1-9.
  6. Keller EC. cellulitis mimics. Cleveland Clinic Journal Of Medicine. 79: 8 2012 547- 552

Stroke 2018 Update

In March New Stroke guidelines came out. Wow are they aggressive! tPA and endovascular therapy (EVT) for all… forget what the literature says! Well We NEED to know these so I’ve listed them here for reference. Sorry about the format. I’ll pretty it up soon!

Stroke. 2018;49:e46–e99. DOI: 10.1161/STR.0000000000000158.)

  1. A primary goal of achieving door-to-needle (DTN) times within 60 minutes in 50% of AIS patients treated with IV alteplase should be established.
  2. It may be reasonable to establish a secondary DTN time goal of achieving DTN times within 45 minutes in 50% of patients with AIS who were treated with IV alteplase.
  3. Systems should be established so that brain imaging studies can be performed within 20 minutes of arrival in the ED in at least 50% of patients who may be candidates for IV alteplase and/or mechanical thrombectomy.
  4. The CT hyperdense MCA sign should not be used as a criterion to withhold IV alteplase from patients who otherwise qualify.
  5. Routine use of magnetic resonance imaging (MRI) to exclude cerebral microbleeds (CMBs) before administration of IV alteplase is not recommended.
  6. Use of imaging criteria to select ischemic stroke patients who awoke with stroke or have unclear time of symptom onset for treatment with IV alteplase is not recommended outside a clinical trial.
  7. For patients who otherwise meet criteria for EVT, it is reasonable to proceed with CTA if indicated in patients with suspected intracranial LVO before obtaining a serum creatinine concentration in patients without a history of renal impairment.
  8. In selected patients with AIS within 6 to 24 hours of last known normal who have LVO in the anterior circulation, obtaining CTP, DW-MRI, or MRI perfusion is recommended to aid in patient selection for mechanical thrombectomy, but only when imaging and other eligibility criteria from RCTs showing bene t are being strictly applied in selecting patients for mechanical thrombectomy.
  9. Only the assessment of blood glucose must precede the initiation of IV alteplase in all patients.
  10. Supplemental oxygen is not recommended in nonhypoxic patients with AIS.
  11. Patients who have elevated BP and are otherwise eligible for treatment with IV alteplase should have their BP carefully lowered so that their systolic BP is <185 mm Hg and their diastolic BP is <110 mm Hg before IV brinolytic therapy is initiated.
  12. Hypoglycemia (blood glucose <60 mg/dL) should be treated in patients with AIS.
  13. IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) is recommended for selected patients who may be treated within 3 hours of ischemic stroke symptom onset or patient last known well or at baseline state. Physicians should review the criteria outlined in Table 6 to determine patient eligibility.
  14. IV alteplase (0.9 mg/kg, maximum dose 90 mg over 60 minutes with initial 10% of dose given as bolus over 1 minute) is also recommended for selected patients who can be treated within 3 and 4.5 hours of ischemic stroke symptom onset or patient last known well. Physicians should review the criteria outlined in Table 6 determine patient eligibility.
  15. For otherwise eligible patients with mild stroke presenting in the 3- to 4.5-hour window, treatment with IV alteplase may be reasonable. Treatment risks should be weighed against possible bene ts.
  16. In otherwise eligible patients who have had a previously demonstrated small number (1–10) of CMBs on MRI, administration of IV alteplase is reasonable.
  1. In otherwise eligible patients who have had a previously demonstrated high burden of CMBs (>10) on MRI, treatment with IV alteplase may be associated with an increased risk of sICH, and the bene ts of treatment are uncertain. Treatment may be
  2. IV alteplase for adults presenting with an AIS with known sickle cell disease can be bene cial.
  1. IV alteplase should not be administered to patients who have received a treatment dose of low-molecular-weight heparin (LMWH) within the previous 24 hours.
  2. Patients should receive mechanical thrombectomy with a stent retriever if they meet all the following criteria: (1) prestroke mRS score of 0 to 1; (2) causative occlusion of the internal carotid artery or MCA segment 1 (M1); (3) age ≥18 years; (4) NIHSS score of ≥6; (5) ASPECTS of ≥6; and (6) treatment can be initiated (groin puncture) within 6 hours of symptom onset.
  3. Although the bene ts are uncertain, the use of mechanical thrombectomy with stent retrievers may be reasonable for carefully selected patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the MCA segment 2 (M2) or MCA segment 3 (M3) portion of the MCAs.
  4. Although the bene ts are uncertain, the use of mechanical thrombectomy with stent retrievers may be reasonable for carefully selected patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have causative occlusion of the anterior cerebral arteries, vertebral arteries, basilar artery, or posterior cerebral arteries.
  5. Although its bene ts are uncertain, the use of mechanical thrombectomy with stent retrievers may be reasonable for patients with AIS in whom treatment can be initiated (groin puncture) within 6 hours of symptom onset and who have prestroke mRS score >1, ASPECTS <6, or NIHSS score <6, and causative occlusion of the internal carotid artery (ICA) or proximal MCA (M1). Additional randomized trial data are needed.
  6. In selected patients with AIS within 6 to 16 hours of last known normal who have LVO in the anterior circulation and meet other DAWN or DEFUSE 3 eligibility criteria, mechanical thrombectomy is recommended. (LEVEL I recommendation)
  7. In selected patients with AIS within 16 to 24 hours of last known normal who have LVO in the anterior circulation and meet other DAWN eligibility criteria, mechanical thrombectomy is reasonable. (Level IIA Recommendation)
  8. Defuse Critereia: Age 18-90 years; NIHSSS ≥ 6; femoral puncture within 6 -16 hours of stroke onset/last known well; pre- morbid mRS2≤2; ICA or M1 occlusion by MRA or CTA AND Target Mismatch Profile on CT perfusion or MRI (ischemic core volume is <70 ml, mismatch ratio is >1.8 and mismatch volume is >15 ml)
  9. Dawn Criteria: Age 18;
failed or contraindicated for IV t-PA; NIHSS ≥10; Pre-stroke -mRS 0-1; Time last seen well to Randomization: 6-24h; <1/3 MCA territory by CT or MRI; ICA- T and/or MCA- M1 occlusion;- Clinical Imaging Mismatch:
A. 80 y/o, NIHSS 10 + core <21 mL B. <80 y/o, NIHSS 10 + core <31 mL C. < 80 y/o, NIHSS 20 + core <51 mL
  10. Administration of aspirin is recommended in patients with
AIS within 24 to 48 hours after onset. For those treated with
IV alteplase, aspirin administration is generally delayed until
24 hours later but might be considered in the presence of concomitant conditions for which such treatment given in the absence of IV alteplase is known to provide substantial bene t or withholding such treatment is known to cause substantial risk.
  11. In patients presenting with minor stroke, treatment for 21 days with dual antiplatelet therapy (aspirin and clopidogrel) begun within 24 hours can be bene cial for early secondary stroke prevention for a period of up to 90 days from symptom onset. The generalizability of this intervention in non-Asian populations remains to be established, and a large phase III multicenter trial in the United States, Canada, Europe, and Australia is ongoing.195
  12. In patients with BP 220/120 mm Hg who did not receive IV alteplase or EVT and have no comorbid conditions requiring acute antihypertensive treatment, the bene t of initiating or reinitiating treatment of hypertension within the rst 48 to 72 hours is uncertain. It might be reasonable to lower BP by 15% during the rst 24 hours after onset of stroke.
  13. Routine placement of indwelling bladder catheters should not be performed because of the associated risk of catheter-associated urinary tract infections.
  14. Use of brief moderate hyperventilation (Pco2 target 30–34
mm Hg) is a reasonable treatment for patients with acute severe neurological decline from brain swelling as a bridge to more de nitive therapy.
  15. Hypothermia or barbiturates in the setting of ischemic cerebral or cerebellar swelling are not recommended.
  16. Because of a lack of evidence of ef cacy and the potential to increase the risk of infectious complications, corticosteroids (in conventional or large doses) should not be administered for the treatment of cerebral edema and increased intracranial pressure complicating ischemic stroke.
  17. Prophylactic use of anti-seizure drugs is not recommended.

ATLS 10th Edition 2018 Update

Since summer is closing and  “Fall” is upon us I thought it would be a good time to “drop” some Trauma knowledge especially since “Crash (2)” is in the ATLS update. Here are the major changes in the 10th Edition of ATLS. Luckily ATLS is getting closer to the evidence and what many of us are already doing. Of course it wouldn’t be an ACS program without their special stamp of approval so they had to change some names around. For example for some reason RSI is now called Drug Assisted intubation. I still think RSI has a better ring to it. Sorry for the format… I”ll update soon!

ATLS 10thEdition changes

Initial Assessment

  • 1 L of fluid
    • Bolus “isotonic” solution 1 L for adults and 20ml/kg for peds <40kg
    • Early blood
  • MTP (1:1:1)
  • TXA
  • Canadian Cspine and nexus

Airway

  • RSI is now Drug assisted Intubation
  • VL vs DL

Shock Table

  • Base excess added to shock table
  • Early use of blood
  • Management of Coagulopathic patients
  • TXA
    • TXA over 10 min withing 3 horus of injury
    • 1 g over 8 hour infusion after bolus

Thoracic Trauma

  • Flail chest is out
  • Tracheobronchial injury in
  • Tension
    • Needle
      • 5thICS MAL for adult
      • 2ndICS for child
    • 28-32Fr (vs 36-40)
  • Circulatory arrest algorithm
  • Aortic rupture with bb goal HR <80 MAP 60-70
  • Life threatening injuries during primary survey
    • Airway
      • Obstruction
      • Tracheobronchial tree injury
    • Breathing
      • Tension Pnx
      • Open Pnx
    • Circulation
      • Massive Hmthx (1500)
      • Cardiac Tamponade
      • Traumatic circulatory arrest

Abdominal Trauma

  • No more prostate palpation “no high riding prostate”
  • Flow chart for pelvic fx amended
  • “gentle palpation of the bony pelvis for tenderness”
  • An AP pelvic x-ray may help to establish the source of blood loss in hemodynamically abnormal patients and in patients with pelvic pain or tenderness. An alert, awake patient without pelvic pain or tenderness does not require a pelvic radiograph.

Head Injury

  • Maintain SBP >100 mmHg for adults 50-69
  • Maintain SBP >110 for adults 15-49 or >70
  • Goals of Brain injury
    • Clinical:
      • SBP >100
      • Temp 36-38
    • Monitoring
      • CPP >60 mmhg
      • ICP 5-15
      • PBtO2 >15 mmHg
      • Pulse ox >95%
    • Labs
      • Glucose 80-180
      • Hgb >7
      • INR <1.4
      • Na 135-145
      • PaCO2 35-45
      • pH 7.35-7.45
      • Plt >75000
    • Szr prophyaxis
      • PTS – Postratumatic seizures (wthin in 7 days of injury)
      • Prophylactic use not recommended
      • Phenytoin is recommended todecrease the incidene o faerly posttraumatic szr when benefit is felt to more than harm. Hwevver early PTS has not been associated with worse outcomes

C-spine

  • Terminology changed to restriction of spinal motion
  • New myotome diagram
  • Canadian Cspine and Nexus

MSK Trauma

  • Wt based IV abx regimen

Thermal injuries

  • 2ml/kgxwtx%burn adults
  • 3ml/kgxwtx%burn children
  • Fluid titrated to UO
  • Flame vs electrical all ages are 4ml/kg LR x%TBSA

Pediatric Trauma

  • Needle thoracentesis unchanged
  • Limiting crystalloid
    • 20 ml/kg bolus followed by blood 10-20 ml/kg rbc or ffp and platelet
  • PECARN

Transfer to Definitive Care

  • Specific mention of avoiding CT in primary hospital
    • “Do not peform procedures (DPL or CT) that do not change the plan of care
  • SBAR for communcation