Medical Video Review Live Tweet: Elevated intracranial pressure

Check out the series of tweets from today’s lecture on elevated intracranial pressure by Mary Frey, RN and Andrea Rinderknecht, MD at Cincinnati Children’s Hospital Medical Center and the Division of Emergency Medicine. Check out these tweets for a summary of the many high yield teaching points.

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Why we do what we do: Systemic corticosteroids in acute asthma exacerbations

There are some things that we seem to do reflexively in the ED. Giving steroids to a patient with an asthma exacerbation is one of those things. Ask yourself the following question. Why do we do this? What is the evidence behind it? Can you cite any of the studies that lead to this common practice? I couldn’t fully elaborate on these – thus I’ve chosen it as the theme for this edition of WWDWWD.

How do they work?

Systemic glucocorticoids work just like the natural ones made in the adrenals (the kidney’s hat). They bind with glucocorticoid receptors- forming a complex, which then interacts with DNA to alter transcription of genes responsible for lots of stuff. In the case of asthma exacerbations this includes inflammatory mediators.

OK, prove it

Way back in 1993 (when I was a sophomore in high school) Scarfone et al demonstrated that children with a moderate asthma exacerbation who received prednisone as opposed to placebo had reduced risk of admission to the hospital. A meta-analysis from 2001 (when I was a second year med student) further supported the use of steroids in asthmatics. Rowe et al. noted that early ED administration within 1 hour of presentation was associated with reduced rate of admission. This meta analysis included a dozen RCT studies of almost 900 total patients. The pooled OR was 0.40, 95% CI: 0.21 to 0.78. The estimated number needed to treat is 8 95% CI 5-21. Children that didn’t get steroids before coming to the ED had a NNT of 7 and OR 0.37, 95% CI: 0.19 to 0.70. This probably means that these children were a bit sicker since they had already gotten steroids prior to their sentinel ED visit. Side effects were not significantly different between corticosteroid treatments and placebo.

Who should get them?

Basically, children with moderate exacerbations or worse. Children that have not received inhaled beta-agonists within a few hours of arrival to the ED and those that respond promptly and completely to a single dose do not benefit from steroids.

What is the usual dose & schedule for oral medications?

There are a few options:

  • Prednisone/Prednisolone 1mg/kg orally – max 60mg/dose – once daily for 5 days (Fun-fact: Prednisone is metabolized into prednisolone in the liver)
  • Dexamethasone 0.6mg/kg orally – max 10mg – once daily for one or two days

When should they be given?

ASAP – That much is clear. Zemek et al noted in their investigation of 644 children with asthma exacerbations that the administration of oral steroids by triage nurses reduced the odds of admission OR = 0.56; 95% CI: 0.36-0.87. Children ended up getting steroids 44 minutes earlier when they were administered in triage. Recall that steroids take at least 2-4 hours to start working – so this difference is important. As you’d expect, patents that got steroids in triage were better quicker – time to “mild” status median difference: 51 minutes; 95% CI: 17-84; P = .04. They were also discharged home faster – time to discharge median difference: 44 minutes; 95% CI: 17-68; P = .02. If your ED doesn’t do this you should be asking why.

Does it matter which one I administer?

Nope.

Both oral prednisone and oral dexamethasone work great. This meta-analysis from Keeney et al. looked at 6 RCTs comparing the two aforementioned agents (single or 2-dose dexamethasone versus 5 days of prednisone) and noted the following:

  • No difference in risk of relapse at 5 days RR 0.90, 95% CI 0.46-1.78  /  10-14 days RR 1.14, 95% CI 0.77-1.67  /  or 30 days RR 1.20, 95% CI 0.03-56.93
  • Patients who got dex vomited less often in the ED RR 0.29, 95% CI 0.12-0.69  /  and at home RR 0.32, 95% CI 0.14-0.74.

You can check out this previous edition of our PEM Currents podcast to hear more about prednisone versus dexamethasone.

Does the route of administration matter?

If the child can tolerate oral medicines – then give the steroids by mouth. Trust me, they will prefer that route. This is supported by the National Asthma Education and Prevention Program. There are no significant advantages to the IV route. You should consider giving the dose IM if they vomit the oral dose if you don’t need an IV for any other reason. This is supported by numerous studies, principally the following.

  • Gries et al., 2000: The authors noted in this RCT that IM dexamethasone was associated with a similar improvement in clinical asthma score over the 5 days following the ED visit.  Children were randomized to 5 days of 2/kg/day oral prednisone or 1x IM Dexamethasone. Additionally, there was no significant difference was seen in the rate of improvement between the 2 groups. Of note, many children in this study missed at least half of their oral steroid doses. There were no IM injectuon related complications. Nearly three out of four parents would choose IM again.
  • Gordon et al, 2007This study was a prospective, randomized trial in children aged 18 months to 7 years who presented to the ED with a moderate asthma exacerbation or worse. They were randomized to 1 dose of IM dexamethasone (0.6 mg/kg, max 15 mg) or oral prednisolone 2 mg/kg for 5 days. They found that there was no difference in clinical score at 4 days or rate of readmission by 2 weeks for either group.

Inhaled steroids for acute exacerbations is still being investigated. The data comparing oral versus inhaled is inconclusive at best.

Are there any downsides?

A short course of  prednisone at 1-2mg/kg will not effect bone density, height, or adrenal function at 30 days. There may be transient, clinically insignificant impact of bone deposition and adrenal function however.  There doesn’t seem to be a conclusive increases in nausea, tremor, and headache when compared with placebo. Studies have shown that kids getting 2mg/kg/day had more behavioral side effects than 1mg/kg/day. See Kayani et al. for more.


Summary

Please, keep administering systemic corticosteroids for children with moderate exacerbations of asthma. You can choose either 1mg/kg (max 60mg) of PO prednisone/prednisolone  for 5 days or 1-2 days of dexamathasone 0.6mg/kg (max 10mg). If the PO route isn’t gonna happen, consider going IM if you don’t need the IV for anything else (like fluids or Magnesium). And finally, get them into the patient ASAP as it will increase the speed of their clinical improvement and decrease their time in dpeartment

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Briefs: Exam based approach to the patient with a sore throat

The Differential Diagnosis for sore throat is quite long, though it is usually infectious.  I will approach the approach that you should consider using when you approach the patient with a sore throat. I hope I don’t face reproach for the gratuitous approach laden approach.

Does the patient have respiratory distress?

If the answer is yes to this one stop everything and assess the airway. Stridor that accompanies sore throat and dysphagia could signal epiglottitis, retropharyngeal abscess or peritonsillar abscess or foreign body. Though it is true that many of the patients with these conditions can protect their airway is up to us to determine whether they can continue to maintain it or if their disease process will immanently worsen. Patients are drooling and cannot handle their secretions are worrisome as are those with an unintelligible voice.

A unilaterally enlarged tonsil and uvular deviation in a patient with a peritonsillar abscess The thumb sign in a patient with epiglottitis Lateral neck X-Ray indicating an enlarged prevertebral soft tissue plan consistent with retropharyngeal abscess

And remember, when facing an agitated patient with a potentially compromised airway keep them calm! Airway resistance on inspiration can increase fourfold when the child is crying or upset. So keep a parent close by. You should be able to carefully inspect the pharynx and clinically diagnose a PTA. If you’re concerned that the patient has epiglottitis and they’re stable and lateral neck X-Ray can be diagnostic. Finally, if you have to intubate this patient be careful, very careful… Awake fiber-optic intubation or securing the airway in the operating room are too safe approaches.

Does the patient have inflammation of the gums or buccal mucosae?

Herpetic gingivostomatitis leads to inflammation of the gums and anterior oral mucosae. You will often note that they are beefy red before you see the characteristic ulcerative lesions. Very ill appearing patients with sloughing of the buccal mucosae and lips might have Stevens-Johnson syndrome, an illness that presents like sepsis and is the only true Derm condition that will get them to come in at 2 AM.

Inflamed gums in a patient with herpetic gingivostomatitis Sloughing of the tongue seen in Stevens-Johnson syndrome

Is the pharynx erythematous and inflamed?

The answer to this one is probably yes – since this is the most common finding you’ll see in the ED. Infectious pharyngitis can cause minimal erythema all the way up to beefy swelling with copious exudates. These findings could signal Group A Strep, mono or respiratory viruses (like adenovirus). Strep pharyngitis could be up to 30-50% of cases of sore throat when there are winter outbreaks, but may be less common at other times. A rapid strep antigen test, or careful use of the Centor score can help. And of course, strep is known to look a myriad of different ways.

Strep pharyngitis This is also a case of strep pharyngitis Strep throat as well This is strep pharyngitis Strep pharyngitis right here

Viruses are the other common etiology of course. Mono has been known to look exactly like strep. When you see ulcers on the posterior pharynx – especially during summer outbreaks think about coxsackie hand, foot and mouth (and butt) disease.

Mucosal lesions in hand, foot and mouth disease

Mucosal lesions in hand, foot and mouth disease

And don’t forget that children with Kawasaki will have oral changes as well. These should go hand in hand with the other diagnostic criteria – but in isolation the pharynx could look similar to other infectious causes.

Are there any exposures I should be concerned about?

Well, some cases of irritative pharyngitis are due to exposure to forced, heated air in the winter. You may see this in a kid who just attended a sleepover and whose mother is worried that he caught strep throat from his sleepover mates. The exam however will be normal, and the kid should be well appearing. Chemical burns can present with mild erythema initially, with liquefactive necrosis setting in later for high pH alkali burns (lye). You should also be highly suspicious of esophageal injuries in such patients. Patients with a normal exam may have globus hystericus AKA psychogenic pharyngitis. This is usually associated with anxiety (exposed to stressful stuff) and will present with subjective sore throat and frequent and difficult swallowing (and probably a few negative strep tests along the way).

 

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Check out these amazing joint exam videos

I know that performing an accurate and efficient joint exam in the ED can be challenging. Reviewing an ideal example in a “just in time” fashion can be a wonderful way to prepare for an upcoming patient. With that in mind I wanted to direct you to an excellent online resource from the Heart of England Foundation Trust’s Emergency Department. You can check out their entire series of musculoskeletal exam videos here.

I’ve also embedded the knee exam video:

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Fracture Fridays: Forearm fracture reduction

The case(s)

You are seeing a pair of siblings that crashed into each other while jousting on their bikes. They were wearing helmets but both sustained forearm injuries. Both have swollen, tender forearms and you get X-Rays. And, no, there is not a BOGO discount.

Forearm AForearm B

The Diagnosis

Both patients have forearm fractures. Patient A has a buckle, or torus fracture. This occurs when the bone is compressed and the cortex buckles, often when the child falls on an outstretched hand (FOOSH). Patient B’s fracture is notably more angulated and represents diaphyseal fractures of both the radius and ulna with apex-volar angulation. It is also a complete fracture, since the cortex has been broken through.

Management

Patient A has a stable injury that requires splinting and pain relief. A volar or sugartong splint will suffice.

Volar Splint (Courtesy WikiEM) Sugar Tong Splint (Courtesy WikiEM)

 Torus fractures heal incredibly well and may actually do just as well with a removable splint as with a short arm cast (see Plint et al for more). Nevertheless, you must differentiate them from a Greenstick fracture (see below) since that one definitely needs a cast. Note that the Greenstick fracture is different than that of Patient B, since the cortex is not completely broken.

Greenstick fracture

Greenstick fracture

 

Patient B obviously has the more significant injury. It will require reduction, perhaps with ketamine. General criteria for forearm fractures that DO NOT require reduction are as follows:

  1. Nondisplaced isolated radial shaft fractures with <15 to 20 degrees angulation can be splinted in a sugar tong splint or casted without reduction in kids under the age of 10 years. Physical function at six weeks in children randomized to reduction or casting initially was similar in a trial by Boutis et al.
  2. Minimally displaced radial shaft fractures with the following features can be immobilized without reduction
    • Lateral shift <2mm
    • Dorsal angulation <10 degrees
    • Shortening of <2mm
    • Bayonet apposition without angulation or rotational deformity in children <10 years

      Bayonet apposition

      Bayonet apposition

Fractures that DO require immediate closed reduction include

  1. Displaced fractures
  2. Greater than 20 degrees of angulation

When in doubt you can discuss any fracture with your friendly neighborhood Orthopod. In general children who are angulated >10 degrees and who are older than 10 years are candidates for closed reduction. Patients that don’t need reduction should be splinted and follow up with Orthopedics within the next 5-7 days.

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