Contributor: Aaron Lessen, MD

Educational Pearls:

• If a patient sustains a cut, the provider has several options on how to close the wound. If they choose to suture the wound closed, it involves needles both in the form of injecting numbing medication (lidocaine) as well as with the suture itself. Other techniques are “needleless,” like closing the wound with adhesive strips (Steri-Strips) or skin adhesive (Dermabond). But which method is best?

• A recent study looked to compare guardian-perceived cosmetic outcomes of pediatric lacerations repaired with absorbable sutures, Dermabond, and Steri-Strips. It also assessed pain and satisfaction with the procedure from both guardian and provider perspectives.

• Participants: 55 patients were enrolled; 30 completed the 3-month follow-up.

• • Cosmetic Ratings (Median and IQR):

  • • Sutures: 70.5 (59.8–76.8)

    • Dermabond: 85 (73–90)

    • Steri-Strips: 67 (55–78)

    • (P = 0.254, no statistically significant difference)

  • Satisfaction and Pain:

  • • No significant differences in guardian or provider satisfaction

    • Pain levels were comparable across all methods

• Even though there was no statistically significant difference in guardian-perceived cosmetic outcomes, the Dermabond did have the highest ratings at the end of the study.

References

• Barton, M. S., Chaumet, M. S. G., Hayes, J., Hennessy, C., Lindsell, C., Wormer, B. A., Kassis, S. A., Ciener, D., & Hanson, H. (2024). A Randomized Controlled Comparison of Guardian-Perceived Cosmetic Outcome of Simple Lacerations Repaired With Either Dermabond, Steri-Strips, or Absorbable Sutures. Pediatric emergency care, 40(10), 700–704. https://doi.org/10.1097/PEC.0000000000003244

Summarized by Jeffrey Olson MS3 | Edited by Meg Joyce, MS1 & Jorge Chalit, OMS3

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Contributor: Jorge Chalit-Hernandez, OMS3

Educational Pearls:

• Serotonin syndrome occurs most commonly due to the combination of monoamine oxidase inhibition with concomitant serotonergic medications like SSRIs

• Examples of unexpected monoamine oxidase inhibitors

  • Linezolid - a last-line antibiotic reserved for patients with true anaphylaxis to penicillins and cephalosporins

  • Methylene blue - not mentioned in the podcast due to its uncommon usage for methemoglobinemia

• Other medications that can interact with SSRIs to cause serotonin syndrome

  • Dextromethorphan - primarily an anti-tussive at sigma opioid receptors that also has serotonin reuptake inhibition

• Clinical presentation of serotonin syndrome

  • Altered mental status

  • Autonomic dysregulation leading to hypertension (most common), hypotension, and tachycardia

  • Hyperthermia

  • Neuromuscular hyperactivity - tremors, myoclonus, and hyperreflexia

• Hunter Criteria (high sensitivity and specificity for serotonin syndrome):

  • Spontaneous clonus

  • Inducible clonus + agitation or diaphoresis

  • Ocular clonus + agitation or diaphoresis

  • Tremor + hyperreflexia

  • Hypertonia, temperature > 38º C, and ocular or inducible clonus

• Management of serotonin syndrome

  • Primarily supportive - benzodiazepines can help treat hypertension, agitation, and hyperthermia. Patients often require repeated and higher dosing of benzodiazepines

  • Avoid antipyretics to treat hyperthermia since the elevated temperature is due to sustained muscle contraction and not central temperature dysregulation

  • In refractory patients, cyproheptadine (a 5HT2 antagonist) may be used as a second-line treatment

  • Patients with temperatures > 41.1º C or 106º F require medically induced paralysis and intubation to control their temperature

References

1. Boyer EW, Shannon M. The serotonin syndrome [published correction appears in N Engl J Med. 2007 Jun 7;356(23):2437] [published correction appears in N Engl J Med. 2009 Oct 22;361(17):1714]. N Engl J Med. 2005;352(11):1112-1120. doi:10.1056/NEJMra041867

2. Dunkley EJ, Isbister GK, Sibbritt D, Dawson AH, Whyte IM. The Hunter Serotonin Toxicity Criteria: simple and accurate diagnostic decision rules for serotonin toxicity. QJM. 2003;96(9):635-642. doi:10.1093/qjmed/hcg109

3. Ramsay RR, Dunford C, Gillman PK. Methylene blue and serotonin toxicity: inhibition of monoamine oxidase A (MAO A) confirms a theoretical prediction. Br J Pharmacol. 2007;152(6):946-951. doi:10.1038/sj.bjp.0707430

4. Schwartz AR, Pizon AF, Brooks DE. Dextromethorphan-induced serotonin syndrome. Clin Toxicol (Phila). 2008;46(8):771-773. doi:10.1080/15563650701668625

5. Thomas CR, Rosenberg M, Blythe V, Meyer WJ 3rd. Serotonin syndrome and linezolid. J Am Acad Child Adolesc Psychiatry. 2004;43(7):790. doi:10.1097/01.chi.0000128830.13997.aa

Summarized & Edited by Jorge Chalit, OMS3

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Contributor: Aaron Lessen, MD

Educational Pearls:

• Many patients present to the ED with elevated BP

• • Many are referred from outpatient surgery centers or present after an elevated measurement at home

• Persistent questions on the best way to treat these patients

• The AHA published a scientific statement on the management of elevated BP in the acute care setting

• • Hypertensive emergencies: SBP/DBP >180/110–120 mm Hg with evidence of new or worsening target-organ damage

  • • Includes aortic dissection or subarachnoid hemorrhage

    • Require aggressive treatment

  • Asymptomatic markedly elevated inpatient BP: SBP/DBP >180/110–120 mm Hg without evidence of new or worsening target-organ damage AND asymptomatic elevated inpatient BP: SBP/DBP ≥130/80 mm Hg without evidence of new or worsening target-organ damage

  • • No benefits to urgent treatment in the ED, but there are harms to treating patients in this manner

    • These patients do not require IV medications

    • Provide reassurance and instructions on following up with their PCP to manage their BP in the outpatient setting

  • Removed the term “hypertensive urgency”

References

1. Bress AP, Anderson TS, Flack JM, et al. The Management of Elevated Blood Pressure in the Acute Care Setting: A Scientific Statement From the American Heart Association. Hypertension. 2024;81(8). doi:https://doi.org/10.1161/hyp.0000000000000238

Summarized by Meg Joyce, MS1 | Edited by Meg Joyce & Jorge Chalit, OMS3

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