ED Push - May 2016 Second Issue
| Free Monthly News from the Award Winning Publisher of: | |
|
Emergency Medicine Reports |
Trauma Reports |
| Pediatric Emergency Medicine Reports | ED Management |
| ED Legal Letter | Critical Care Alert |
New Guidelines Issued on Treating Drowning in ED
JACKSONVILLE, FL – As the weather warms up, emergency departments see more patients suffering the effects of drowning. More than 3,800 drowning deaths occur in the United States each year, with children 1 to 4 years old who die in residential pools the highest risk group.
The Wilderness Medical Society (WMS) recently issued new guidelines on the treatment of drowning, published in the society's official journal, Wilderness and Environmental Medicine. A team of researchers graded available evidence according to the American College of Chest Physicians criteria.
"Drowning is a process defined by hypoxemia, with outcomes ranging from no morbidity to severe morbidity, and eventually death," explained lead author Andrew C. Schmidt, DO, MPH, assistant professor of Emergency Medicine at the University of Florida College of Medicine in Jacksonville, and director of Lifeguards Without Borders.
Clinical deterioration tends to occur within the first four to eight hours for patients presenting with mild symptoms after drowning, requiring the monitoring of lung sounds, oxygen saturation, and blood pressure, according to the report. For events occurring in the wilderness, the guidelines recommend emergency care if patients exhibit hypoxemia; abnormal lung sounds; severe cough; frothy sputum or foamy material in the airway; depressed mentation; or hypotension.
In terms of post-resuscitation management, the guidelines recommend that mechanical ventilation should follow acute respiratory distress syndrome (ARDS) protocols. The document also suggests that initial chest radiographs could be useful in tracking changes in patient condition but not for determining prognosis.
The document does not call for routine use of neuroimaging in awake and alert drowning patients, however, unless a change in clinical status occurs. Also not recommended is routine complete blood count or electrolyte testing, although arterial blood gas testing might be used for patients who show signs of hypoxemia or respiratory distress in order to guide respiratory interventions.
The guidelines cite a lack of data and evidence on the use of routine antibiotics and corticosteroids, suggesting those might be employed in extenuating clinical circumstances that demand their use.
While current literature indicates that therapeutic hypothermia could offer some benefits to drowning patients, the researchers failed to find enough evidence to either support or discourage its use.
The article points to research suggesting that patients who experience a drowning event but have no symptoms other than a mild cough (and do not have abnormal lung sounds) are almost certain to survive. On the other hand, if a patient is submerged for more than 30 minutes in water warmer than 6°C (43°F) or more than 90 minutes in water colder than 6°C (43°F), the guidelines suggest there is minimal chance of the patient surviving the event neurologically intact.
Patients can be safely discharged from the ED after stabilization if there was no deterioration in respiratory function after four to eight hours of observation on room air, according to the recommendations.
"When prevention fails, or circumstance leads to the drowning process,” Schmidt emphasized, “then the most important aspect of treatment is to reverse cerebral hypoxia by providing oxygen to the brain by whatever means available."
Pediatric Firework Injuries Increase at EDs as States Relax Regulations
LOUISVILLE, KY – The number of children — and the severity of their injuries — presenting to emergency departments with fireworks-related burns is on the upswing, according to a new study that points out the trend appears to track the loosening of state laws regulating pyrotechnics.
The research was presented recently at the Pediatric Academic Societies 2016 Meeting in Baltimore. For the study, researchers reviewed the National Inpatient Sample, with data on 8 million hospital stays each year, and the Nationwide Emergency Department Sample, which annually compiles information on 30 million discharges from emergency medicine facilities.
Although they found the number of patients younger than age 21 treated and released by EDs for fireworks injuries went up modestly from 2006 and 2012, much larger increases were identified for injuries requiring inpatient hospital admission, which rose from 29% of cases in 2006 to 50% in 2012.
"The increase in fireworks-related injuries and the severity of these injuries in children since 2006 are very concerning," said co-author Charles Woods, MD, associate chair of pediatrics at the University of Louisville. "Although our findings do not prove a direct link to relaxations in state laws governing fireworks sales, it may be time for lawmakers to reassess this issue. Parents and caregivers of children also should be aware of these increasingly serious injuries and the potential dangers involved in allowing young children to handle and play with fireworks.”
Background information in the study notes that changes in U.S. fireworks laws have allowed younger children to purchase fireworks, as well as allowing individuals to purchase more powerful ones.
Results of the study indicate that the 3,193 injuries reviewed represented an estimated 90,257 firework-related burn injuries treated in the United States from 2006 to 2012.
Most of the injuries, 62.9%, were managed in EDs, with incidence increasing over time from 4.28 per 100,000 in 2006 to 5.12 per 100,000 in 2012.
In addition to the increase in the proportion of injuries requiring inpatient admission, researchers also documented longer lengths of stay, from 3.12 days in 2006 to 7.35 days in 2012. At the same time, the average age of the injured decreased from 12.1 years old in 2006 to 11.4 years old in 2012.
“Pediatric fireworks-related burn injuries have increased in incidence, apparent severity of injury, the proportion requiring hospitalization and LOS (in the hospital) in a time period of relaxed fireworks laws in the U.S.,” study authors conclude. “Fireworks laws may need to be revisited by policy-makers.”
Dangers of Using Anti-Diarrheal for Opioid Addiction, Legal High
SYRACUSE, NY – Trying to self-treat an opioid addiction with loperamide, marketed as the anti-diarrhea medication Imodium, is a dangerous game. So is using the product for a legal “high.”
That’s according to the Annals of Emergency Medicine, which recently published two new case studies online.
"Loperamide's accessibility, low cost, over-the-counter legal status and lack of social stigma all contribute to its potential for abuse," explained lead study author William Eggleston, PharmD, of the Upstate New York Poison Center, in Syracuse, NY. "People looking for either self-treatment of withdrawal symptoms or euphoria are overdosing on loperamide with sometimes deadly consequences. Loperamide is safe in therapeutic doses but extremely dangerous in high doses."
The case studies describe cases in which, after ingesting massive doses of loperamide, two patients overdosed and emergency medical services were called. Despite treatment with cardiopulmonary resuscitation, naloxone, and standard Advanced Cardiac Life Support, both died.
Loperamide is an over-the-counter antidiarrheal with μ-opioid agonist activity, according to the report, which points out that central nervous system opioid effects are not observed after therapeutic oral dosing because of poor bioavailability and minimal central nervous system penetration. Central nervous system opioid effects occur after supratherapeutic oral doses, however, and ventricular dysrhythmias and prolongation of the QRS duration and QTc interval have been reported after oral loperamide abuse, study authors emphasize.
The article also notes that oral loperamide abuse postings to web-based forums increased 10-fold between 2010 and 2011, with most loperamide content, 70%, related to using the medication to self-treat opioid withdrawal. Another 25% discussed abusing the medication because it can cause euphoria.
The report says that the Upstate New York Poison Center had seven times as many calls related to loperamide abuse or misuse in 2015, compared to 2011. National poison data, meanwhile, suggested a 71% increase in calls related to intentional loperamide use from 2011 through 2014.
"Our nation's growing population of opioid-addicted patients is seeking alternative drug sources with prescription opioid medication abuse being limited by new legislation and regulations," Eggleston said in an American College of Emergency Physicians press release. "Healthcare providers must be aware of increasing loperamide abuse and its under recognized cardiac toxicity. This is another reminder that all drugs, including those sold without a prescription, can be dangerous when not used as directed."
Study Calls into Question Pediatric Concussion Return-to-Activity Guidelines
OTTAWA, CANADA – Should emergency physicians instruct children with sports-related head injuries to avoid returning to play and all other physical activities until all concussion symptoms, including headache, have resolved?
That’s what the guidelines recommend, but a research abstract presented at the Pediatric Academic Societies (PAS) 2016 Meeting suggests otherwise. Researchers from the Children's Hospital of Eastern Ontario and the University of Ottawa report that those who exercise within a week of injury, despite symptoms, have nearly half the rate of concussion symptoms that last more than a month.
For the study, researchers surveyed 3,063 children between the ages of 5 and 18 — or parents/caregivers — who visited Canadian EDs about their level of physical activity and severity of symptoms 7, 14, and 28 days after injury.
Despite the widely followed recommendations, most (58%) of the children still experiencing concussion symptoms reported that they resumed exercising a week after being injured, with 76% reporting physical activity two weeks later.
Rather than suffering ill effects from defying medical guidelines, the patients’ non-compliance tended to be linked to faster recovery, according to the report.
"Exercise within seven days of injury was associated with nearly half the rate of persistent post-concussive symptoms, or those that last beyond a month," said principal investigator Roger Zemek, MD. He said the findings were in line with some previous smaller studies questioning the benefits of prolonged physical rest — essentially longer than three days — following an acute concussion.
"This is the first large-scale study to provide support for the benefits of early exercise on symptom recovery following acute pediatric concussion, shifting away from conservative rest towards more active physical rehabilitation recommendations," Zemek said.
He added that children shouldn’t resume activities “that could put them at risk of re-injury, like contact sports drills or games, until they are cleared by a doctor" but might try light aerobic activity such as walking, swimming, or stationary cycling.
The researchers called for more studies on the issue but suggest that re-introducing exercise sooner after injury could help reduce the undesired effects of physical and mental deconditioning.
"If earlier re-introduction of physical activities is, in fact, confirmed to be beneficial to recovery," Zemek said in an American Academy of Pediatrics press release, "this would have a significant impact on the well-being of millions of children and families worldwide and cause a major shift in concussion management."
 Upcoming Webinars |
|||||||||
|
|||||||||
