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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Contributor: Megan Hurley MD

Educational Pearls:

What is the mediastinum?

• The thoracic cavity is separated into different compartments by membranes

• The lungs exist in their own pleural cavities, and the mediastinum is everything in between

• The mediastinum extends from the sternum to the thoracic vertebrae and includes the heart, the aorta, the trachea, the esophagus, the thymus, as well as many lymph nodes and nerves.

What is a pneumomediastinum?

• Air in the mediastinum

How can pneumomediastinum be categorized?

• Traumatic

• • Ex. Stab wound to the trachea

  • Ex. Boerhaave’s Syndrome of the esophagus, possibly from an endoscopic procedure. This mechanism in particular is a higher risk of infection because not only air but food can accumulate in the mediastinum

  • Ex. Intubation with a bougie

  • These will likely need surgical repair

• Nontraumatic

• • Ex. Forceful inhalation causing microperforations in the trachea. Possibly while inhaling something like drugs

  • Ex. Bad asthma for similar reasons

  • Ex. Gas forming bacteria

What happens if you use positive pressure ventilation on a patient with a hole in their trachea?

• The positive pressure will force extra air into the mediastinum

• The air will move between the layers of subcutaneous tissue and can track up into the neck and face regions recognized as crepitus on exam

• This can also cause a tension pneumomediastinum in which the air pressure in the compartment constricts the heart, impeding its ability to fill during diastole

• These patients can undergo bronchoscopy because that procedure does not require positive pressure and will not worsen the condition. Endoscopies do require positive pressure so endoscopies are not an option

How is a tension pneumomediastinum treated?

• By inserting a needle into the space from below the xiphoid process to allow the air to escape, similar to a pericardiocentesis

• As a temporizing measure, if the hole is high enough in the trachea, the intubation can be continued by deliberately pushing the endotracheal tube into the right main bronchus, creating a seal, and only ventilating the right lung while the patient heads to surgery. This is called right-mainstemming.

References

1. Clancy DJ, Lane AS, Flynn PW, Seppelt IM. Tension pneumomediastinum: A literal form of chest tightness. J Intensive Care Soc. 2017 Feb;18(1):52-56. doi: 10.1177/1751143716662665. Epub 2016 Aug 3. PMID: 28979537; PMCID: PMC5606356.

2. Grewal, J., & Gillaspie, E. A. (2024). Pneumomediastinum. Thoracic surgery clinics, 34(4), 309–319. https://doi.org/10.1016/j.thorsurg.2024.06.001

3. Underner, M., Perriot, J., & Peiffer, G. (2017). Pneumomédiastin et consommation de cocaïne [Pneumomediastinum and cocaine use]. Presse medicale (Paris, France : 1983), 46(3), 249–262. https://doi.org/10.1016/j.lpm.2017.01.002

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

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Contributor: Ricky Dhaliwal MD

Educational Pearls:

• Etomidate was previously the drug of choice for rapid sequence intubation (RSI)

• • However, it carries a risk of adrenal insufficiency as an adverse effect through inhibition of mitochondrial 11-β-hydroxylase activity

• A recent meta-analysis analyzing etomidate as an induction agent showed the following:

• • 11 randomized-controlled trials with 2704 patients

  • Number needed to harm is 31; i.e. for every 31 patients that receive etomidate for induction, there is one death

  • The probability of any mortality increase was 98.1%

• Ketamine is preferable due to a better adverse effect profile

• • Laryngeal spasms and bronchorrhea are the most common adverse effects after IV push

  • Beneficial effects on hemodynamics via catecholamine surge, albeit not as pronounced in shock patients

• 2023 meta-analysis compared ketamine and etomidate for RSI

• • Ketamine’s probability of reducing mortality is cited as 83.2%

  • Overall, induction with ketamine demonstrates a reduced risk of mortality compared with etomidate

• The dosage of each medication for induction

• • Etomidate: 20 mg based on 0.3 mg/kg for a 70 kg adult

  • Ketamine: 1-2 mg/kg (or 0.5-1 mg/kg in patients with shock)

• Patients with asthma and/or COPD also benefit from ketamine induction due to putative bronchodilatory properties

References

1. Goyal S, Agrawal A. Ketamine in status asthmaticus: A review. Indian J Crit Care Med. 2013;17(3):154-161. doi:10.4103/0972-5229.117048

2. Koroki T, Kotani Y, Yaguchi T, et al. Ketamine versus etomidate as an induction agent for tracheal intubation in critically ill adults: a Bayesian meta-analysis. Crit Care. 2024;28(1):1-9. doi:10.1186/s13054-024-04831-4

3. Kotani Y, Piersanti G, Maiucci G, et al. Etomidate as an induction agent for endotracheal intubation in critically ill patients: A meta-analysis of randomized trials. J Crit Care. 2023;77(April 2023):154317. doi:10.1016/j.jcrc.2023.154317

Summarized & Edited by Jorge Chalit, OMS3

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Contributor: Aaron Lessen MD

Educational Pearls:

• Pregnant patients at high risk of cardiac arrest, in cardiac arrest, or in extremis require special care

• A useful mnemonic to recall the appropriate management of critically ill pregnant patients is TOLDD

• T: Tilt the patient to the left lateral decubitus position

• • This position relieves pressure exerted from the uterus onto the inferior vena cava, which reduces cardiac preload

  • If the patient is receiving CPR, an assistant should displace the uterus manually from the IVC towards the patient’s left side

• O: Administer high-flow adjunctive oxygen

• L: Lines should be placed above the diaphragm

• • Lines below the diaphragm are ineffective due to uterine compression of the IVC

  • May consider humeral interosseous line vs. internal jugular or subclavian central line

• D: Dates should be estimated

• • > 20 weeks, can consider a resuscitative hysterotomy (previously known as perimortem c-section) to improve chances of survival

  • The uterus is palpable at the umbilicus at 20 weeks and 1 cm superior to the umbilicus for every week thereafter

• D: Call the labor and delivery unit for additional help

References

1. ACOG Practice Bulletin No. 211 Summary: Critical Care in Pregnancy. Obstetrics & Gynecology. 2019;133(5)

2. Fujita N, Higuchi H, Sakuma S, Takagi S, Latif MAHM, Ozaki M. Effect of Right-Lateral Versus Left-Lateral Tilt Position on Compression of the Inferior Vena Cava in Pregnant Women Determined by Magnetic Resonance Imaging. Anesth Analg. 2019;128(6):1217-1222. doi:10.1213/ANE.0000000000004166

3. Jeejeebhoy FM, Zelop CM, Lipman S, et al. Cardiac Arrest in Pregnancy. Circulation. 2015;132(18):1747-1773. doi:doi:10.1161/CIR.0000000000000300

4. Singh, Ajay; Dhir, Ankita; Jain, Kajal; Trikha, Anjan1. Role of High Flow Nasal Cannula (HFNC) for Pre-Oxygenation Among Pregnant Patients: Current Evidence and Review of Literature. Journal of Obstetric Anaesthesia and Critical Care 12(2):p 99-104, Jul–Dec 2022. | DOI: 10.4103/JOACC.JOACC_18_22

Summarized & Edited by Jorge Chalit, OMS3

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Contributor: Travis Barlock MD

Educational Pearls:

What is the ST segment?

• The ST segment on an ECG represents the interval between the end of ventricular depolarization (QRS) and the beginning of ventricular repolarization (T-wave).

• It should appear isoelectric (flat) in a normal ECG.

What if the ST segment is elevated?

• This is evidence that there is an injury that goes all the way through the muscular wall of the heart (transmural)

• This is very concerning for a heart attack (STEMI) but can be occasionally caused by other pathology, such as pericarditis

What if the ST segment is depressed?

• This is evidence that only the innermost part of the muscular wall of the heart is becoming ischemic

• This has a much broader differential and includes a partial occlusion of a coronary artery but also any other stress on the body that could cause a supply-and-demand mismatch between the oxygen the coronaries can deliver and the oxygen the heart needs

• This is called subendocardial ischemia

What else should you look for in the ECG to identify subendocardial ischemia?

• The ST-depressions should be at least 1 mm

• The ST depressions should be present in leads I, II, V4-6 and a variable number of additional leads.

• There is often reciprocal ST elevation in aVR > 1 mm

The most important thing to remember when you see subendocardial ischemia is…history

• Still, keep all cardiac causes on your differential, such as unstable angina, stable angina, Prinzmetal angina, etc.

• Also consider a wide array of non-cardiac causes such as severe anemia, severe hypertension, pulmonary embolism, COPD, severe pneumonia, sepsis, shock, thyrotoxicosis, stimulant use, DKA, or any other state that lead to reduced oxygen supply to the subendocardium and/or increased myocardial oxygen demand.

References

1. Birnbaum, Y., Wilson, J. M., Fiol, M., de Luna, A. B., Eskola, M., & Nikus, K. (2014). ECG diagnosis and classification of acute coronary syndromes. Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc, 19(1), 4–14. https://doi.org/10.1111/anec.12130

2. Buttà, C., Zappia, L., Laterra, G., & Roberto, M. (2020). Diagnostic and prognostic role of electrocardiogram in acute myocarditis: A comprehensive review. Annals of noninvasive electrocardiology : the official journal of the International Society for Holter and Noninvasive Electrocardiology, Inc, 25(3), e12726. https://doi.org/10.1111/anec.12726

3. Cadogan, E. B. a. M. (2024, October 8). Myocardial Ischaemia. Life in the Fast Lane • LITFL. Retrieved December 7, 2024, from https://litfl.com/myocardial-ischaemia-ecg-library/#:~:text=ST%20depression%20due%20to%20subendocardial,left%20main%20coronary%20artery%20occlusion.

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

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Contributor: Alec Coston MD

Educational Pearls:

• Causes of seizures in a fairly well-appearing child with diarrhea:

• • Electrolyte abnormalities: hypocalcemia, hyponatremia

  • • Also hyperkalemia which causes arrhythmias and syncope - can appear like seizures

  • Hypoglycemia

• If the child has diarrhea and appears very sick, differential diagnosis may include:

• • Hemolytic uremic syndrome (HUS):

  • • simultaneous occurrence of microangiopathic hemolytic anemia, thrombocytopenia, and acute kidney injury

    • Typically caused by Shiga-like toxin producing Escherichia coli (also known as EHEC, or enterohemorragic E. coli)

    • One of the main causes of acute kidney injury in children

  • Toxic ingestions such as salicylates, lead, or iron

• In this case, the child had a seizure but appeared well and was afebrile:

• • Consult with neurology led to a diagnosis of benign convulsions with mild gastroenteritis (CwG)

  • • First identified in 1982 in Japan

    • Viral gastroenteritis with diarrhea and convulsions but does not include fever, severe dehydration, or electrolyte abnormalities

    • Uncommon illness caused by rotavirus and norovirus pathogens

  • Criteria for discharge is similar to a febrile seizure - the patient had one seizure that lasted less than 15 minutes and he quickly returned to his baseline, so he was able to be safely discharged home

  • • This diagnosis does not predispose him to epilepsy later in life

References

1. Lee YS, Lee GH, Kwon YS. Update on benign convulsions with mild gastroenteritis. Clin Exp Pediatr. 2022 Oct;65(10):469-475. doi: 10.3345/cep.2021.00997. Epub 2021 Dec 27. PMID: 34961297; PMCID: PMC9561189.

2. Mauritz M, Hirsch LJ, Camfield P, et al. Acute symptomatic seizures: an educational, evidence-based review. Epileptic Disorders. 2200;1(1). doi:https://doi.org/10.1684/epd.2021.1376

3. ‌Noris, Marina*; Remuzzi, Giuseppe*, †. Hemolytic Uremic Syndrome. Journal of the American Society of Nephrology 16(4):p 1035-1050, April 2005. | DOI: 10.1681/ASN.2004100861

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

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