Pearl of the day - Nebulized Analgesia

To paraphrase Dr. Sergey Motov: when IV access is unattainable or undesirable, nebulized, intranasal and transmucosal administration of analgesics should be considered for acute pain management in the ED. The best evidence is from a systematic review of nebulized fentanyl (see citation).

The doses (off-label use) are: 4mcg/kg for an adult titrated up to three doses. Peds: 2-4mcg/kg. For morphine: 0.2mg/kg peds, 10mg or 20mg adults fixed-dose.

We can use the breath-actuated nebulizer (pic) to ensure patient-controlled dosing. It is located in the pyxis or from pharmacy. If you still don’t know how to use it, ask!

Manufacturer video: https://www.youtube.com/watch?v=7Xk-tYhhEdU

See this article for more information:

Thompson JP, Thompson DF. Nebulized Fentanyl in Acute Pain: A Systematic Review. Annals of Pharmacotherapy 2016, Vol 50(10): 882-891.

Rapid Board-Style Review of Orthopedic Injuries to the Foot/Ankle

SALTER HARRIS I -> S-slipped -> non-op

II -> A-Above physis (through metaphysis) -> non-op

III -> L-Lower than physis (through epiphysis) -> unstable

IV ->T-Throuh physis (all 3 involved) ->limb-length discrepancy->Op

V ->R-ERasure of growth plate (crush) -> Op

ANKLE/FOOT injuries.

▪Achilles tendon rupture – weekend warriors, cipro use, -> + Thompson test – no plantar flexion w/ calf compression -> splint in equine position, ortho eval.

▪Ottawa ankle rules – pain at posterior edge of either malleoli, inability to bear weight immediately/in ED. Navicular TTP, TTP at base of 5th metatarsal

▪Weber ankle fractures -> unstable fractures are types B/C at or below the ankle joint -> OR

▪Trimalleolar fx -> OR

▪Maisonneuve fx – Eversion injury -> proximal fibula fx + medial malleolus fx + disruption of syndesmosis

▪Plafond or pilon fx – comminuted distal tibia -> look for associated injuries

▪Calcaneus fx – most common tarsal bone fx <20 degrees Bohler’s angle -> look for associated injuries such as vertebrae

▪Talus bone is most susceptible foot bone to AVN (also scaphoid, odontoid, femoral head)

▪ATFL (ligament) – Inversion injury (most common ankle sprain).

▪ (left pic) Jones fx -> 5th metatarsal shaft fx -> NWB -> Op

▪(right pic) Pseudojones fx -> 5th metatarsal avulsion fx -> hard sole shoe -> most non-op

▪Tarsal tunnel syndrome -> posterior tibial N neuropathy -> weak flexors, pain on sole of foot.

▪Morton’s neuroma -> pain between 2nd/3rd toes usually

▪Plantar fasciitis -> worst in morning, better after use. Tx: rest/NSAIDs

▪Lisfranc fx -> Joint between base of 1st, 2nd metatarsals and cuneiform disrupted. Most require OR.

▪Plantar puncture wounds -> staph/strep most common. Pseudomonas concern if punctured through shoe. Abx controversial

Acute Gastroenteritis (AGE) in Children

Evidence Based Guidelines for AGE in children We see and treat acute gastroenteritis (AGE) in the pediatric ED every day. For most, oral rehydration therapy after ondansetron (ORTAZ) is the mainstay of treatment. In fact, a meta-analysis looking at oral rehydration solution (ORS) and traditional IV hydration showed only a 3-4% failure rate of ORS. Here are a few evidence-based pearls and pitfalls to guide your management.

2. “The triage note says the patient is here for nausea/vomiting/diarrhea. I will wait until after an initial PO trial before I order medications.” In order to promptly treat nausea/vomiting due to suspected AGE, we are obviously going to institute ondansetron Ondansetron has a good safety profile at appropriate doses. The overwhelming majority of children will only have mild to moderate dehydration and should be rehydrated with a balanced ORS only. Giving juice or soda (high glucose, minimal sodium) may worsen an already existent osmotic diarrhea. IV fluids are indicated only in severe dehydration or in children who are unable to take ORS enterally.
3. “I didn’t find out that the patient had hypoglycemia until the electrolyte panel came back.” If you are starting IV hydration in a child that you suspect has severe dehydration, point-of-care glucose testing should be performed rather than waiting for the formal metabolic panel. Young children have low glucose reserves and can easily develop hypoglycemia when they are dehydrated. Hypoglycemia should be treated promptly.
4. “My patient bounced back 2 days later with severe dehydration. She looked great when I discharged her. I thought the parents would know what to bring her back for.” Avoid the assumption that parents know signs of dehydration. Counsel them that if symptoms persist, they must be able to replace the fluid losses and also give maintenance fluids. If they cannot, they should return to the ED. Probiotics can be prescribed or recommended for children with AGE early in the course of their illness. This may help decrease the duration of their diarrhea by approximately 24 hours and could decrease the need of further interventions and medications.
5. “I prescribed azithromycin for my patient who had diarrhea for the last 4 days because I was afraid she might have a bacterial infection.” In all well-appearing children and most ill children, antibiotics should not be started until there is confirmation of a bacterial pathogen in the stool via stool culture or C.diff assay. Initiating antibiotics may unnecessarily harm the patient. Do not forget to ask about a history of recent travel, drinking from fresh water streams/lakes, and recent antibiotics use.

source: ebmedicine.net

Commonly tested board topic:

Bacterial gastroenteritis -> E.Coli O157:H7 (Shiga like toxin) -> hemolytic uremic syndrome -> microangiopathic hemolytic anemia (schistocytes), renal failure, thrombocytopenia -> Tx is to avoid abx, supportive, transfusion/plasma exchange if indicated, eculizumab if CNS involvement.

source: RoshReview