PEM Pearls: Hydrocortisone stress-dosing in adrenal insufficiency for children

Hydrocortisone stress-dosing in adrenal insufficiencyDuring your shifts in the pediatric ED, you may encounter a few patients with adrenal insufficiency or adrenal crisis. Some of the most common causes include those patients with Addison disease, pituitary hypothalamic pathology, and those patients on chronic steroids. When these patients get sick or sustain trauma, it is important to consider giving them a stress dose of hydrocortisone. Patients in adrenal insufficiency or crisis can present with dehydration, weakness, nausea, vomiting, confusion, lethargy, and severe hypotension refractory to vasopressors.

Commonly, the recommended dose of hydrocortisone is 50 mg/m2.  Measuring the m2 is a reflection of the Body Surface Area (BSA), which in the acute setting, such as the emergency department, it can be difficult to calculate.

Dr. Sonny Tat (UCSF Assistant Professor of EM and Pediatrics) remembers it by thinking about the loose change in his pocket. The Coin Mnemonic which allows you to quickly estimate the initial stress dose of hydrocortisone. Check out the 2-minute Trick of the Trade video, if you are a visual learner.

Animated Video on Hydrocortisone Stress-Dosing (Trick of the Trade)

  • For small-sized kids (neonates to 3 years old), give 25 mg IV/IM (or think of a quarter)
  • For medium-sized kids (3-12 years old), give 50 mg IV/IM (or think of a half-dollar)
  • For large-sized kids (12+ years old), give 100 mg IV/IM (or think of a dollar coin).

For further detail, you can also check out CHOP’s algorithm for treating pediatric patients in adrenal crisis.

References

References

  1. Idrose, AM. “Chapter 225, Adrenal Insufficiency and Adrenal Crisis,”  Tintinalli’s Emergency Medicine, 7th Edition, 2011.
  2. The Royal Children’s Hospital Melbourne, “Adrenal crisis and adrenal insufficiency.” March 2016.
  3. The Children’s Hospital of Philadelphia, “Pathway for the Child at Risk for HPA Suppression: Stress Steroid Dosing and Weaning Recommendations.” September 2014.

Author information

Delphine Huang, MD

Delphine Huang, MD

Emergency Medicine resident

UCSF-San Francisco General Hospital Residency Program

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IDEA Series: A Novel Flipped-Classroom Approach to Intern Conference Education featuring EM Fundamentals

light bulb gears - canstockphoto21333055

The Problem

Delivering a curriculum of core content to interns is both a priority and a challenge. Weekly conference provides time to deliver such a curriculum; however, varied rotation schedules limit consistent conference attendance, and intern-targeted content is inappropriate for upper-level residents. We addressed these challenges by implementing a flipped-classroom intern curriculum using training level-specific breakout sessions and a dedicated resource for asynchronous learning.

The Innovation

EM Fundamentals is a free and open-access asynchronous curriculum featuring third-party FOAM content, primary literature, and institutional protocols. We use EM Fundamentals to support a flipped-classroom approach to small-group breakout sessions at weekly conference.

EM Fundamentals Banner

Learners

Our curriculum was developed for emergency medicine (EM) interns at the University of Chicago; however, we hope that our materials and strategy will be readily adapted to fit the needs of EM interns across the country.

Group Size

While our online asynchronous resources are available to anyone at any time, we have 16 interns who participate in the weekly small-group breakout sessions.

Materials

  • Asynchronous Content: Our web curriculum targets 25 topics, each of which have customized goals, objectives, and resources for asynchronous learning. Resources are identified by way of topic searches, past experience, and recommendations from faculty and residents (both local and remote — each page includes a link to suggest additional content). Promising resources are reviewed for quality by the creators prior to posting.
  • Flipped-Classroom Sessions: We dedicate 1 hour of weekly conference to case-based, small-group sessions led by a member of the faculty or fellow. Many facilitators run sessions with off-the-cuff cases to stimulate discussion so no additional materials are required once a knowledgeable facilitator and time to meet are established.

Curriculum Development

A group of educators identified a need to provide consistent core content for interns, the breadth of which required a year-long design.

We conducted a needs assessment across all 6 Chicago EM residency programs (n = 300, 51% response rate) that confirmed the need for an intern curriculum (80% stated this would improve education) and learner interest in our proposed format (75% in favor of dedicated conference time, 71% in favor of dedicated asynchronous resources). This same survey was used to create a pool of the highest-yield topics as assessed by learners. For content validity, the final 25 topics were hand-picked by a team of expert educators using this pool for reference.

We created a website to host the asynchronous resources (EMFundamentals.blogspot.com) with content pages tailored to include topic-specific goals, objectives, and educational resources (e.g. journal articles, podcasts, institutional guidelines). For interns attending conference, faculty- or fellow-led small-group sessions reinforce key concepts. For interns unable to attend, this web-based content delivery ensured a baseline knowledge. Current assessment methods include a post-curriculum attitudinal survey and pre/post knowledge quiz.

EMF Chart

Outcomes

This is our first year with full deployment of the curriculum. Feedback from our pilot year is promising. Each year, 100% of the interns (n = 32 over 2 years) have participated in the program. Our attitudinal survey showed 75% of learners preferred the flipped-classroom model (versus traditional lecture), and 100% of users reported a positive impact from the asynchronous resources. A knowledge test for Kirkpatrick level 2 data has begun this year and plans to collect Kirkpatrick level 3 data via simulation are in development.

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Lessons Learned

This intervention has been well-received by both our residents and program leadership. Ensuring that learners consistently reference the web resources each week continues to be a challenge; however, we have seen significant improvement in weekly references to the site since developing weekly automated email reminders that include the details of the next breakout session and a link to the web curriculum for easy reference. We believe this additional reminder is particularly important for learners that will be unable to attend conference. We have also created a Twitter account (@EMFundamentals) to further engage learners prior to conference.

Upkeep of the website has also proven to be a non-trivial task. After the substantial activation energy of getting the site online and populated with initial content, reassessment of each page and its content is undertaken 2 weeks prior to the respective live session. This ensures revisions for content updates and removal of dead links at least once per year. Content pages are also updated out of rotation whenever a major release occurs in one of the topic areas (e.g. Sepsis-3 paper added to the sepsis page this spring). Those planning to develop similar resources should also factor these tasks into the webmaster’s workload.

Educational Theory

Our curriculum was developed using Kern’s 6-step approach to curriculum development and leverages the popularity of flipped-classroom teaching amongst our target learners. A log of our progress throughout the development of this resource is available on the curriculum design page of the EM Fundamentals website.

kern curriculum 2

Read more about the IDEA Series.

First photo credit: (c) Can Stock Photo

Author information

Eric Shappell, MD

Chief Resident
Department of Emergency Medicine
University of Chicago

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HOT OFF THE ALiEM PRESS | ALiEM MEdIC Series, Volume 2

MEdICYear2BookCoverThe ALiEM Medical Education in Cases (MEdIC) Series has been a regular feature of our website for almost 3 years.  It has been previously featured as a Top 5 What Works abstract at the International Conference on Residency Education in 2014. At the time of our ICRE presentation, we presented our free e-book of our first years’ cases.  Now, it’s time for our second edition.

HOT OFF THE PRESS: ALIEM MEDIC SERIES (Year 2)

As before, we would like to give a big thank you to the ALiEM and #FOAMed community at large for participating in all our discussions and helping us to craft this work.  We are pleased to announce that a fully edited version of our MEdIC cases from the 2014-2015 season is now available as a free book available in PDF form via ResearchGate (32 mb)!

To get the book, you simply need to register via the form below.  You may email us directly if you are unable to access the free e-book in this manner.

As you are downloading the e-book, we are always looking for participation and engagement from the #FOAMed community. Check out our cases from this year (and other years) at our MEdIC page.

Download MEdIC Volume 2 e-book here now for free (32 mb) by filling out the following form.

Once you submit the form, you will be given the link for the e-book!

 

 

MEDIC BOOK CITATION

Chan TM, McColl T, Luckett-Gatopoulos S, Purdy E, Thoma B (Eds). (2016). Medical Education in Cases: Volume 2 (1st Edition). Digital File. San Francisco, CA; Academic Life in Emergency Medicine. ISBN: 978-0-9907948-4-4. DOI: 10.13140/RG.2.1.4240.6803.

Learn more about the MEdIC Series

Author information

Teresa Chan, MD

ALiEM Associate Editor
Emergency Physician, Hamilton
Assistant Professor, McMaster University
Ontario, Canada
+ Teresa Chan

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Synthetic cannabinoid use reaches new heights: K2 is not just a mountain on the China-Pakistan boarder

K2You are working a shift in the emergency department, and you hear the ambulance sirens. EMS is bringing you two patients, friends from a nearby shelter. Per report, the two men were “smoking drugs” together outside of the shelter. Bystanders noted that the 29-year-old man became increasingly agitated, shouting, banging on the door, and threatening his other shelter mates, while the other, a 50-year-old man, laid down on the sidewalk. EMS also reports picking up these patients in an area known for high “K2” use.

Synthetic Cannabinoids: Background

Synthetic cannabinoids (SC), sometimes called synthetic cannabinoid receptor agonists (SCRA), were originally developed to allow investigation of the human endocannabinoid receptor system. As more was learned about this endogenous system, interest grew in their use as therapeutic drugs for various medical ailments, such as the alleviation of the gastrointestinal side effects of chemotherapeutic agents. These compounds interact with the cannabinoid (CB) receptors as does delta-9-tetrahydrocannabinol (THC), the psychoactive component in Cannabis, but they are structurally different and generally more potent [1-3].

Currently, SCs can be classified into several different types: [1, 4]

  • Aminoalkylindoles
  • Cyclohexylphenols
  • Benzylindoles
  • THC analogues (also referred to as classic synthetic cannabinoids)

Synthetic chemists, primarily in China, can create hundreds of different SCs, and this helps account for the unpredictable clinical effects seen in the ED. The HBO video below elaborates about the production of SCs in China.

Growing popularity of SC’s

SCs entered the “black market” in 2004 as a novel class of designer drugs marketed with names such as “Spice” and “K2.” Since then, they have grown in popularity throughout Europe and North America. Initially SCs were sold legally (“hidden in plain sight”) as an alternative to Cannabis and they became readily available in gas stations, head shops, and over the Internet. Because of the chemicals’ high potencies and small volumes needed, they are often sprayed onto a bulky substance (e.g., crushed dried plant matter) that resembles Cannabis to allow for easy delivery. It is impossible to predict the dose of SCs associated with any product mainly because of the method in which they are produced (i.e. the bulky plant matter can have any amount of SCs or none at all). The average cost in 2010 was approximately $20-30 per 3 grams of herbal material [5]. In 2012, the Monitoring the Future survey on adolescent drug use reported that about 12% of 12th-graders use SCs [6].

Despite legal efforts since 2011 to ban these substances, SC use has skyrocketed in urban areas, predominantly among the homeless population. Its falling price, as low as five dollars per “bag” containing from four to ten grams, its association with a “stronger high” when compared to Cannabis, and its easy accessibility all add to its popularity [3, 7]. With recent seizures in small shops in New York City yielding over two million packages, the supply of SCs appears to be so vast that this may account for its dropping price. In addition, SCs’ inconspicuous nature (i.e they are not detected by standard drug testing for THC) made them popular in schools and among athletes.

This New York Times article depicts the more current use of SCs in east Harlem [7].

Can SC’s be easily detected in the urine today?

The answer is still NO. The most common urine drug screen still used today is the EMIT, or enzyme mediated immunoassay technique, specifically designed to detect a chemical structure present above a specified cutoff of detection. Currently, some assays screen for “cannabinoid” but typically only detect THC-COOH (a metabolite of THC) at concentrations greater only than 50 ng/mL. At best, newer urine drug tests detect the original SCs such as JWH-018, which are no longer in widespread use. Newer SCs are structurally very different from THC and JWH-018 [Figure 1]. Therefore, the newer SCs continue to evade routine testing.

Figure 1. Cannabis and synthetic cannabinoids. [4]

How are SC’s marketed, and what is the problem with calling it “synthetic marijuana” or “K2?”

SCs are being marketed as “synthetic marijuana” for 2 reasons already mentioned:

  1. They are often crushed dried plant matter onto which synthetic compounds are sprayed or soaked.
  2. This synthetic product binds to the same receptor as THC.

However, referring to these products as synthetic marijuana is misleading because Cannabis is a plant and not a chemical. Furthermore, the clinical effects do not resemble those of marijuana use. THC is mainly responsible for the psychoactive effect of Cannabis. It is a partial agonist at the CB1 and CB2 receptors, whereas SCs are full agonists at these receptors [1, 3]. Furthermore, Cannabis contains over 60 other cannabinoid compounds, one of which is cannabidiol (CBD). CBD has non-psychoactive effects that occur through antagonism at CB1 receptors [8, 9, 12]. In fact, CBD is being evaluated as an anti-epileptic agent due to its neuroinhibitory effects. Some theorize that adjusting the THC:CBD ratio may help abate the psychoactive effects of Cannabis. SCs lack CBD and other compounds found in Cannabis, possibly contributing to their greater potency and association with more severe toxicity.

SCs collectively are commonly referred to as “K2,” which was one of the original “brand names” for these drugs. However, this too is misleading, because SC products are now being marketed with names such as “Clown,” “Scooby Snax,” “Green Giant,” “iBlown,” “Ninja,” and “Loopy,” among many others. They are packaged in small bags and labeled “not for human consumption” to evade legal scrutiny. However, this “caveat” placed on the packaging has largely served as a covert marker for the actual intent of the product [1, 3]. A package can contain one SC, more than one SC, none at all, and there may even be variability in the SC content within a given brand product. Newer SCs that have been discovered in products include AB-Chiminaca, AB-Fubinaca, AB-Pinaca, MAB-Chiminaca, and LXR-11.

How are SC’s classified and what are the clinical effects?

Since April 2015, the number of ED visits and calls to Poison Control Centers for SC-related toxicity has skyrocketed. In a single 2-month period, there were over 2,000 SC-related ED visits in New York City alone [10]. Patients tend to present in 1 of 2 ways [13]:

  1. Somnolent, sometimes with other signs/symptoms similar to sedative-hypnotic intoxication including bradycardia or hypotension
  2. Agitated, resembling sympathomimetic use with tachycardia, hypertension, and sometimes seizure activity

Of note, some patients quickly fluctuate from one state to the other. Several deaths with confirmed SC exposure have been reported [11, 13].

How are patients who present with SC intoxication treated?

As with any ED patient, management should begin with managing the airway, breathing, and circulation. In patients with agitation or seizure activity, benzodiazepines should be first-line agents. The use of antipsychotic agents, such as haloperidol, is NOT recommended due to their association with QT prolongation. Furthermore, evidence based support for the safety of ketamine in toxin-induced agitation is still lacking. Ketamine administration in patients with SC-induced agitation may worsen hypertension and tachycardia, and the long-term psychiatric effects are unknown. Additionally, agitated patients should be evaluated for hyperthermia, and cooling measures employed quickly if necessary. They should also be assessed for rhabdomyolysis.

If CNS depression occurs, observation is warranted until the patient returns to baseline mental status. Respiratory depression has not been a consequential problem, but should be assessed and monitored as needed. Hypotension is treated with intravenous crystalloids, and if persistent, vasopressors may be necessary. Bradycardia treatment is rarely required, but should follow standard measures.

Case conclusion

The 29-year-old man with agitation required sedation with midazolam. His initial vital signs were notable for: BP, 145/92 mmHg; HR, 120/min; RR 22/min; T 38C. Once he was adequately sedated, his vital signs normalized and he returned to baseline within approximately 4 hours. The 50-year-old man presented with initial hypotension (88/56 mmHg) with a heat rate of 90 beats per minute. His temperature and respiratory rates were within normal limits. He was given a total of 3 liters of normal saline and was observed for 6 hours prior to discharge with normal mentation and vital signs. They both endorsed daily SC use.

References

  1. Su MK, Seely KA, Moran JH, Hoffman RS. Metabolism of classical cannabinoids and the synthetic cannabinoid JWH-018. Clin Pharmacol Ther. 2015; 97(6):562-4. PMID: 25788107
  2. Shanks KG, Winston D, Heidingsfelder J, Behonick G. Case reports of synthetic cannabinoid XLR-11 associated fatalities. Forensic Sci Int. 2015; 252:e6-9. PMID: 25979131
  3. Seely KA, Lapoint J, Moran JH, Fattore L. Spice drugs are more than harmless herbal blends: a review of the pharmacology and toxicology of synthetic cannabinoids. Prog Neuropsychopharmacol Biol Psychiatry. 2012; 39(2):234-43. PMID: 22561602
  4. The Chemistry of Cannabis & Synthetic Cannabinoids. Compound Interest. Published May 2015. Accessed April 18, 2016.
  5. Reed T. K2: Easily Accessible Substance That Mimics Marijuana – and Is Legal – Sold in Ann Arbor. The Ann Arbor News. Published February 2010. Accessed April 18, 2016.
  6. Monitoring the Future National Survey Results on Drug Use 1975-2012. 2012 Overview, Key Findings on Adolescent Drug Use [PDF]. Accessed April 19, 2016.
  7. Casey N. New York K2, a Potent Drug, Casts a Shadow Over an East Harlem Block. Times. Published Sept 2, 2015. Accessed April 19, 2016.
  8. Friedman D, Devinsky O. Cannabinoids in the Treatment of Epilepsy. N Engl J Med. 2015; 373(11):1048-58. PMID: 26352816
  9. Ameri A. The effects of cannabinoids on the brain. Prog Neurobiol. 1999; 58(4):315-48. PMID: 10368032
  10. Stewart N. New York City Council Initiates Steps to Ban the Manufacture of K2. New York Times. Published September 2015. Accessed April 18, 2016.
  11. Schwarz A. Potent ‘Spice’ Drug Fuels Rise in Visits to Emergency Room. New York Times. Published April 2015. Accessed April 18, 2016.
  12. Mechoulam R, Peters M, Murillo-Rodriguez E, Hanus LO. Cannabidiol–recent advances. Chem Biodivers. 2007; 4(8):1678-92. PMID: 17712814
  13. Trecki J, Gerona RR, Schwartz MD. Synthetic Cannabinoid-Related Illnesses and Deaths. N Engl J Med. 2015; 373(2):103-7. PMID: 26154784

Author information

Denise Fernandez, MD

Denise Fernandez, MD

Senior Medical Toxicology Fellow
New York University Langone Medical Center & Bellevue Hospital Center

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Did the Affordable Care Act actually reduce ED visits as politicians promised?

ACA

The Affordable Care Act (ACA) was supposed to expand coverage to the uninsured and many politicians claimed this would result in lower use of “expensive emergency rooms” for the treatment of patients’ acute complaints. Ignore, for the moment, the controversy about whether or not the emergency department (ED) is an expensive or appropriate place for patients to seek care. A new survey [PDF] from the Center for Disease Control and Prevention (CDC), asked the question: Did the ACA actually reduce ED visits as politicians promised [1]?

Background

This presumption, that increased health insurance coverage would decrease ED visits, runs counter to 2 facts.

  1. Only one-fifth of patients visit the ED due to problems such as their doctor’s office being closed or lack of other providers. The vast majority goes to the ED because they (or any other prudent layperson) think they are having an actual emergency.
  2. recent randomized experiment demonstrated that giving Medicaid to the uninsured in Oregon led to a 40% increase in ED visits [2].

The CDC study did not answer the question about ED visit reduction

The authors used the National Health Interview Survey to assess patterns of ED use among adults age 18-64 in 2013 and 2014 — the years straddling the ACA’s major insurance expansions [1].

Figure 1 ACA - no label

Fig 1. Adults (age 18-64) with ≥1 visit to the ED in the past year, by number of visits, health insurance coverage status, and year: United States (2013 and 2014). Figure from [1].

In this study based on patient recollection, the percentage of people reporting an ED visit during the previous 12 months did not significantly differ between 2013 and 2014. This is true for both the Medicaid and privately insured subgroups. We know that about 10 million people gained insurance coverage due to the ACA’s expansion of Medicaid and through private health insurance marketplaces in 2014. How is it that none of those people ventured their way into an ED?

Contrast these findings to the highly cited Oregon Medicaid experiment clearly demonstrated that the absolute number of total ED visits went up by about 40% during its Medicaid expansion at 18 months [2]. This Oregon study also showed that the percent of patients with any visit, which is the same measure reported by CDC, also significantly increased by about 20%.

So why are the CDC and Oregon studies not in agreement?

Like any other scientific paper, the devil is in the details, or in academic-speak, the methods. The Oregon study results differ from the CDC study in that the former used an administrative database and the latter used patient self-report. A true comparison would require comparing the CDC data to self-reported ED visits. Fortunately, the Oregon researchers provided us that information as well (Figure 2). The in-person interview at 12 months showed no significant difference for patients getting Medicaid on ED visits.

 

 

Figure 2 ACA copy

Fig 2. Comparing ED visit results from administrative data and self-reports. Table from [2]

So ultimately in the end, both the Oregon and the CDC study – looking at a 12 month period – found that patients did not report any significant change in the likelihood of visiting an ED [1,2]. So where did this 40% increase in ED visits in Oregon come from? If you look at Figure 2, the administrative ED data at 18 months clearly show significant increases in percentage of patients with any ED visit and the total number of ED visits.

So maybe it’s true that Obamacare nationally hasn’t changed the overall number or likelihood of visiting the ED – which runs contrary to our predictions – but that might just be the results of the sampling method (self-report vs. administrative database) or too short an observation period (12 vs 18 months).

I would be willing to bet that when researchers look at the real numbers of how many patients actually went to the ED, not just what interviewees say they did (which is subject to recall bias), our predictions of a spike in ED visits will be corroborated.

Bottom line

To honestly answer the question – Did the ACA actually reduce ED visits as politicians promised? This CDC study did not clearly answer the question. What we need is a true analysis of the administrative records, free from recall bias.

 

References

  1. Gindi RM, Black LI, Cohen RA. Reasons for Emergency Room Use Among U.S. Adults Aged 18-64: National Health Interview Survey, 2013 and 2014. Natl Health Stat Report. 2016; (90):1-16. PMID: 26905514
  2. Taubman SL, Allen HL, Wright BJ, Baicker K, Finkelstein AN. Medicaid increases emergency-department use: evidence from Oregon’s Health Insurance Experiment. Science. 2014; 343(6168):263-8. PMID: 24385603

Author information

Cedric Dark, MD MPH

Cedric Dark, MD MPH

Assistant Professor of Medicine
Section of Emergency Medicine
Baylor College of Medicine;
Founder & Executive Editor,
Policy Prescriptions ® (www.policyrx.org)

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