Topics in this EM Quick Hits podcast
Sarah Reid on differentiating septic arthritis from transient synovitis in pediatric limp (18:52)
Anand Swaminathan on managing tracheostomy complications in the ED (27:50)
Nour Khatib on rural medicine and ethylene glycol poisoning (37:52)
Justin Morgenstern on RCTs for ketamine in patients with severe agitation (48:17)
Podcast production, editing and sound design by Anton Helman
Written summary & blog post by Sarah Reid and Anton Helman November, 2021
Cite this podcast as: Helman, A., Swaminathan, A., Khatib, N., Reid, S., H. Carr, D., Morgenstern J. EM Quick Hits 34 – Carr’s Case, Septic Arthritis vs Transient Synovitis, Managing Tracheostomies, Ethylene Glycol Poisoning, Ketamine for Agitation. Emergency Medicine Cases. November, 2021. https://emergencymedicinecases.com/em-quick-hits-november-2021/. Accessed [date].
Pediatric nontraumatic limp – differentiating transient synovitis from acute bacterial osteoarticular infection (septic arthritis, osteomyelitis)
- Age and fever dictate differential for nontraumatic pediatric limp
- Workup to consider:
- CBCD, CRP, blood culture if infection/inflammatory cause suspected to help distinguish between transient synovitis and osteoarticular infection
- US (for effusion, soft tissues) if significant fever and/or elevation of inflammatory markers and/or severe pain
- MRI with gadolinium is the most accurate noninvasive test for osteoarticular infection and should be considered for patients with persistent pain/fever
- Volume of blood matters when obtaining blood for culture and sensitivity which is essential, as hematogenous spread is common in children with osteoarticular infections
Approach to tracheostomy emergencies in the ED
Ethylene glycol poisoning
- Ethylene glycol is a toxic alcohol found in engine coolants, cleaning products, radiator antifreeze, degreasing agents, foam stabilizers and metal cleaners that is intoxicating like ethanol
- As the alcohol (which is nontoxic itself) is metabolized to an acid (which is toxic) patients develop hypotension, tachycardia, tachypnea, depressed level of awareness, renal failure and potentially seizures. The symptoms usually develop over 6-24hrs but can be delayed up to 4 days if ethanol is coingested.
- Diagnostic clues to toxic overdose include tachycardia and tachypnea (in an attempt to blow off CO2), high anion gap metabolic acidosis with high osmolar gap, not sobering up as expected, low ethanol level in a highly inebriated patient
- Early after ingestion an anion gap metabolic acidosis has not had time to develop but osmolality is expected to be high. Later after ingestion an anion gap metabolic acidosis is expected while the osmolality may be normal. Absence of an anion gap metabolic acidosis or high osmolar gap does not rule out toxic alcohol poisoning.
- Coingestion of ethanol delays the toxic effects of ethylene glycol and can be used as an effective treatment when fomepazol antidote is not available.
- Additional treatments besides fomepazol or ethanol includes pyridoxine, correction of acidosis with a bicarbonate infusion to target pH = 7.2, and dialysis
Evidence for ketamine for severe agitation and excited delirium
- The first ever ED RCTs comparing ketamine to haloperidol + benzodiazepine for severely agitated patients were published in 2021
- A randomized, single ED study of 93 patients compared ketamine (4 mg/kg IM or 1mg/kg IV) and haloperidol/lorazepam (haloperidol 5-10 mg IM/IV + lorazepam 1-2 mg IV/IM) with primary outcome of time to sedation, and found ketamine was significantly more effective at both 5 minutes and 15 minutes after medication administration with no statistically significant increase in adverse effects
- Another single-centered, randomized trial of 80 patients comparing ketamine (5 mg/kg IM) and haloperidol/midazolam (5 mg for both), showed a significantly different mean time to sedation of 6 minutes for the ketamine group and 15 minutes for the haloperidol/midazolam group with no statistical difference in serious adverse events
- While there were no statistical difference in serious adverse events, there was a trend toward more adverse events in the ketamine groups
=>Ketamine may be superior to haloperidol + benzodiazepine for rapid sedation of severely agitated patients but is associated with more serious adverse events, and should be considered in selected patients in the prehospital setting when rapid sedation is perhaps more important than in the ED