Answering Reviewers’ Comments

February 14, 2022February 19, 2022 ~ Arif Alper Cevik ~ Leave a comment

In this educational series, iEM Education Project interviewed Prof. Fikri Abu-Zidan, a world-renowned expert and researcher on trauma, POCUS, and disaster management. He shares his 40 years of experience as a clinical researcher with the young generation of doctors.

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 18th episode is “Answering Reviewer’s Comments”

Prof Fikri Abu-Zidan - Short Bio

Professor Fikri Abu-Zidan, the head of the Trauma Group at United Arab Emirates University, is an Acute Care Surgeon who graduated (MD) from Aleppo University (Syria) in 1981 and was awarded the FRCS, Glasgow, Scotland in 1987. He achieved his PhD in Trauma and Disaster Medicine from Linkoping University (Sweden) in 1995 and obtained his Postgraduate Diploma of Applied Statistics from Massey University (New Zealand) (1999). His clinical experience included treating war injured patients during the Second Gulf War (1990). He has been promoting the use of Point-of-Care Ultrasound (POCUS) for more than thirty years in which he is a World Leader. Furthermore, he is an international expert on trauma experimental methodology developing novel clinically relevant animal models. Establishing experimental surgical research in Auckland University, New Zealand, has led to a strong successful PhD Program.

He has made major contributions to trauma management, education and research in Kuwait, Sweden, New Zealand, Australia and UAE. He authored more than 415 publications, presented more than 600 invited lectures and abstracts, and received more than 40 national and international awards. He is serving as the Statistics Editor of World Journal of Emergency Surgery and European Journal of Trauma and Emergency Surgery.

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Question Of The Day #76

February 11, 2022February 12, 2022 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management?

Explanation

This patient arrives to the Emergency department 10 hours after ingesting 11grams of paracetamol (APAP). She has mild symptoms of nausea and upper abdominal discomfort and has normal vital signs.

Paracetamol, also known as acetaminophen or APAP, is a commonly used pain medication safe for use in childhood, pregnancy, and breastfeeding. Paracetamol is an ingredient present in many over the counter pain, headache, and cold medications. Toxic paracetamol doses are acute ingestions over 150mg/kg, or about 10grams in adults. Toxic paracetamol doses for children are 150mg/kg. Multiple ingestions of paracetamol over 24 or 48 hours can also cause toxicity. Ingestions of 10grams over 24hours or 6 grams/day over 48hours can also cause toxicity in adults. Symptoms of acute poisoning can be absent or mild in the first 24 hours as seen in this patient. After 24 hours, AST, ALT, bilirubin, and INR levels begin to increase, and over 72 hours post-ingestion, hepatic failure ensues. 5 days after an acute ingestion is when multi-organ failure occurs or hepatotoxicity resolves (less common). Toxicity of APAP is thought to be caused by a toxic metabolite produced during APAP breakdown in the liver known. This toxin is known as NAPQI.

APAP overdose can be fatal without treatment with the antidote commonly known as NAC, or N-acetylcysteine. NAC is a free radical scavenger and prevents the damage caused by NAPQI. If serum APAP testing is available, APAP levels drawn 4 hours after the time of an acute ingestion are used to determine if NAC is warranted. APAP levels over 150mcg/mL at 4hours are the threshold for starting NAC. This is based on use of the Rumack-Mathew Nomogram for APAP (see below).

Hendrickson RG, McKeown NJ. Acetaminophen. In: Nelson LS, Howland M, Lewin NA, Smith SW, Goldfrank LR, Hoffman RS. eds. Goldfrank’s Toxicologic Emergencies, 11e. McGraw Hill; 2019.

Since this patient’s acute ingestion is above the known 10gram toxic dose, it is reasonable to start N-acetylcysteine therapy (Choice B) without first knowing the exact serum APAP level. PO Activated charcoal (Choice A) can be used after oral ingestions to help bind some toxic substances and prevent their absorption through the GI system. The majority of APAP is absorbed 2-4 hours after ingestion, so charcoal would not be helpful in this case where the ingestion was 10 hours ago. Liver transplantation (Choice C) may ultimately be required for this patient depending on the liver function tests and how the patient responds over the coming days. However, the best next step is NAC treatment to prevent liver failure and death. IV Sodium bicarbonate (Choice D) is used in salicylate and tricyclic antidepressant overdose, but it has no role in APAP overdose. The best next step is IV N-Acetylcysteine (Choice B).

References

Abdrabbo, M. (2018). TOXCard: Acetaminophen toxicity and management. EM Docs. http://www.emdocs.net/toxcard-acetaminophen-toxicity-and-management/
Hendrickson RG. Acetaminophen. In: Goldfrank’s Toxicologic Emergencies 9^th edition. Nelson LS, et al (Eds). New York, NY, McGraw-Hill 2011.

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Submitting A Manuscript To A Journal

February 7, 2022February 19, 2022 ~ Arif Alper Cevik ~ Leave a comment

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 17th episode is “Submitting A Manuscript To A Journal”

Prof Fikri Abu-Zidan - Short Bio

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Question Of The Day #75

February 4, 2022March 20, 2022 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most likely cause of this patient’s condition?

Explanation

This patient presents to the Emergency Department with altered mental status after ingestion of an unknown agent as part of a suicide attempt. Her exam demonstrates hypertension, tachycardia, elevated temperature, disorientation, dilated pupils, and dry and hot skin. Altered mental status has a broad differential diagnosis, including intracranial bleeding, stroke, post-ictal state, hypoglycemia, electrolyte abnormalities, other metabolic causes, infectious etiologies, toxicological causes, and many other conditions. This patient’s history and exam support the presence of a toxidrome. See the chart below for a review of the most common toxidromes (toxic syndromes).

*Treatment of all toxic ingestions should include general supportive care and management of the airway, breathing, and circulation of the patient. Examples include administration of supplemental oxygen in hypoxia, IV fluids in hypotension, cooling measures in hyperthermia, etc.
**Flumazenil is the antidote for benzodiazepine overdose, but it is rarely used clinically as it can trigger benzodiazepine-refractory seizures.

Paracetamol (Choice A) is often accompanied with little to no symptoms in the first 24hours. Later in the ingestion timeline, liver failure and its associated sequalae can occur if no antidote is given. The symptoms exhibited by the patient do not correlate with APAP overdose. Dextroamphetamine (Choice B) is a sympathomimetic agent that could be responsible for many of the patient’s symptoms, like elevated heart rate, hypertension, agitation, and dilated pupils. However, dextroamphetamine should cause diaphoretic skin, not the dry skin that the patient has. Ethanol (Choice C) may be a co-ingested agent in this scenario that could lead to agitation and confusion, but ethanol alone should not cause fever. Diphenhydramine (Choice D) is an antihistamine agent, but it also has anticholinergic properties, especially when taken in excess. This patient has all the signs of an anticholinergic toxidrome. The presence or absence of dry skin can help differentiate a sympathomimetic toxidrome from an anticholinergic toxidrome. Diphenhydramine (Choice D) is the most likely agent responsible for this patient’s symptoms. Correct Answer: D

References

Kitchen, L. (2015). The Approach to the Poisoned Patient. EMDocs. http://www.emdocs.net/the-approach-to-the-poisoned-patient/
Srisuma, S. (2015). Physostigmine for management of anticholinergic toxidrome. EM Docs. http://www.emdocs.net/physostigmine-for-management-of-anticholinergic-toxidrome/

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Selecting The Right Journal

January 31, 2022February 19, 2022 ~ Arif Alper Cevik ~ Leave a comment

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 16th episode is “Selecting The Right Journal”

Prof Fikri Abu-Zidan - Short Bio

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Question Of The Day #74

January 28, 2022December 27, 2021 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most appropriate next step in management for this patient’s condition?

Explanation

This patient presents to the Emergency Department with altered mental status, difficulty breathing, vomiting, and hypersalivation after an unknown ingestion. His exam shows an ill patient with constricted pupils (miosis), wet skin (diaphoresis), bradycardia, and tachypnea. Altered mental status has a broad differential diagnosis, including intracranial bleeding, stroke, post-ictal state, hypoglycemia, electrolyte abnormalities, other metabolic causes, infectious etiologies, toxicological causes, and many other conditions. This patient’s constellation of signs and symptoms support the presence of a cholinergic toxidrome due to organophosphate poisoning. See the chart below for a review of the most common toxidromes (toxic syndromes).

Cholinergic toxidromes can be caused by organophosphate or carbamate pesticides, as well as nerve gas agents (i.e., sarin gas). These agents cause poisoning by increasing the amount of acetylcholine at the neuromuscular junction, causing stimulation at muscarinic and nicotinic acetylcholine receptors. This causes a dramatic increase in bodily secretions with increased respiratory secretions and airway compromise as the most common cause of death in this population. The cholinergic toxidrome can be remembered with the mnemonic “DUMBBELLS” (diarrhea/diaphoresis, urination, miosis, bradycardia, bronchorrhea, emesis, lacrimation, low BP, salivation).

The first step in treating any patient who has the potential cause to harm or expose staff members to the poisoning agent is patient decontamination (Choice C). This patient should be undressed and adequately decontaminated by staff members who are wearing personal protective equipment (PPE). Once the patient is decontaminated, the airway should be established with endotracheal tube placement (Choice A) and IV atropine (Choice B) should be given to reverse the toxidrome. Atropine can be started at 2-4mg IV and repeated every 5-10 minutes until respiratory secretions are cleared. Pralidoxime (Choice D) should also be given as soon as possible to prevent irreversible changes (“aging”) to the acetylcholinesterase at the neuromuscular junction. This timeframe varies from minutes to hours after exposure, depending on the agent. All choices provided in this question are important actions to take, but patient decontamination (Choice C) is the most important initial next step. Correct Answer: C

References

Kitchen, L. (2015). The Approach to the Poisoned Patient. EMDocs. http://www.emdocs.net/the-approach-to-the-poisoned-patient/
Sahi, N. (2018). TOXCard: Nerve agents. EM Docs. http://www.emdocs.net/toxcard-nerve-agents/

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Fine-Tuning Your Manuscript

January 24, 2022February 19, 2022 ~ Arif Alper Cevik ~ Leave a comment

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 15th episode is “Fine-Tuning Your Manuscript”

Prof Fikri Abu-Zidan - Short Bio

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Question Of The Day #73

January 21, 2022December 27, 2021 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most likely cause of this patient’s condition?

Explanation

This patient presents to the Emergency Department with a depressed mental status and normal sized pupils after an unknown toxic ingestion. Many different agents can act as Central Nervous System depressants and cause this clinical presentation. Some examples include ethanol, toxic alcohols (methanol, ethylene glycol, isopropyl alcohol), benzodiazepines, barbiturates, opioids, and muscle relaxants.

Of the choices listed, Heroin (Choice A) and Alprazolam (Choice B) are the most likely. Heroin is an opioid, and Alprazolam is a benzodiazepine (a sedative-hypnotic agent). The clinical presentation caused by overdoses of opioids versus sedative-hypnotic agents overlaps in many areas, but the pupillary exam can help the most in differentiating the type of ingestion. Opioids will can constricted, pinpoint pupils, while benzodiazepines should not cause change in pupillary size. See the chart below for a review of the most common toxidromes (toxic syndromes).

Cocaine (Choice C) is a sympathomimetic with a CNS excitatory effect, not a CNS depressant effect as in this patient. A large ingestion of paracetamol (Choice D) is often accompanied with little to no symptoms in the first 24hours. Later in the ingestion timeline, liver failure and its associated sequalae can occur if no antidote is given. Correct Answer: B

References

Kitchen, L. (2015). The Approach to the Poisoned Patient. EMDocs. http://www.emdocs.net/the-approach-to-the-poisoned-patient/

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Approach to the trauma patient – ABCDE of trauma care

January 19, 2022February 19, 2022 ~ Maryam Bagherzadeh, Canada ~ Leave a comment

Case

Jane Doe, 22-year-old female, was in a major car crash and is approaching the trauma bay via an ambulance. You are aware that the patient’s condition is critical, so you do a quick run-through in your head about the approach that you will have to care for them once they arrive to your emergency department. What should your approach to a trauma patient be?

The ABCDE of Trauma Care

The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is a clinically proven approach to any critically ill patient that needs emergent care and treatment. It has been proven to improve patient outcomes, optimize team performance and save time when patients are in life-threatening conditions [1]. This approach is applicable to all patients (both adults and children), regardless of their underlying condition. However, the ABCDE approach is not applicable to patients who are in cardiac arrest, in which case the cardiopulmonary resuscitation guidelines should be used [2].

With the ABCDE approach, initial assessment and treatment are performed simultaneously. Once the entire survey is completed, reassessment should be conducted until the patient is stable enough for the care team to be able to move on to the secondary survey and look for a definitive diagnosis.

A - Airway

First, the care team should assess if the patient’s airway is patent. If the patient responds to the team in a normal voice, then that is a good sign that the airway is intact. It is important to note that airway obstruction can be complete or partial, and can be caused by upper airway obstruction or reduced level of consciousness.

Signs of complete airway obstruction are lack of respiration despite great effort. Signs of partial airway obstruction include:
– Changes in the patient’s voice
– Snoring or gurgling
– Stridor (noisy breathing)
– Increased breathing effort

Assess the patient’s airway by looking for rocking chest wall motion and any signs of maxillofacial trauma or laryngeal injury. Perform the head-tilt and chin-lift maneuver to open the airway (note that caution should be conducted in patients with C-spine injury). If there is anything that is noticeably obstructing the airway, suction or remove it. If possible, remove foreign bodies that are causing airway obstruction. Provide high-flow oxygen to the critically ill patient and perform definitive airway if needed [1].

B – Breathing

Generally, airway and breathing are examined simultaneously. Determine if breathing is intact by assessing the respiratory rate, inspecting the chest wall movement for symmetry, depth, and respiratory pattern. Additionally, assess for tracheal deviation and use of respiratory muscles. Percuss the chest for dullness or resonance, auscultate for breath sounds and apply a pulse oximeter [1].

Injuries that impact breathing should be immediately recognized, and life-threatening injuries should be addressed and managed [3]. For example, tension pneumothorax must be promptly relieved by needle thoracocentesis, bronchospasms should be managed with inhalation and assisted ventilation should be considered if breathing continues to be insufficient [1].

C – Circulation

Conditions that threaten the patient’s circulation and can be fatal include shock, hypertensive crises, vascular emergencies such as aortic dissection and aortic aneurisms. These conditions should be immediately identified and managed [1].

Circulation can be assessed by looking at the general appearance of the patient, including signs of cyanosis, pallor, flushing and diaphoresis. Assess for any obvious signs of hemorrhage, blood loss and level of consciousness. Additionally, capillary refill time and pulse rate should be assessed. Auscultate the chest for heart sounds, and blood pressure measurement and electrocardiography should be performed as soon as possible [1].

Additionally, assess for signs of hypovolemia and shock. If these are identified, obtain an intravenous access and infuse saline to restore circulating volume [1]. If there are life-threatening conditions that are compromising the patient’s circulation, promptly identify and treat them as needed. For example, tension pneumothorax should be immediately treated with needle decompression and cardiac tamponade can be relived with pericardiocentesis.

D - Disability

The main disability in the primary survey to be assessed for is the brain. Abnormal neurological status can be caused by primary brain injury or systemic conditions that effect brain perfusion, such as shock, hypoxia, intoxication etc. Assess the level of consciousness by using the Glasgow Coma Scale [4], look for pupillary response and limb movement.

The best way to prevent injury to the brain is to maintain adequate airway, breathing and circulation. Glucose levels can be assessed at bedside for decreased level of consciousness due to low blood glucose levels, and corrected with oral or infused glucose [1].

E – Exposure

The exposure portion of the ABCDE approach involves assessment of the whole-body to avoid any signs of missing injuries. During this part of the management, undress the patient fully and examine the back for any signs of C-spine precautions. Additionally, check for clues for any signs of underlying conditions, such as:

Signs of trauma (i.e. burns, gunshot wounds, stab wounds)
Rashes
Causes of sepsis (i.e. infected wounds, gangrene)
Toxins and drugs (i.e. needle track marks, chemicals, patches)
Other wounds such as bite marks, insect bites, embedded ticks
Iatrogenic causes (i.e. catheters, tubes, implants, surgical sites and scars)

Concluding Remarks

The ABCDE approach to the critically ill patient is a strong and proven clinical tool for initial assessment and treatment of patients in medical emergencies. Widespread knowledge of this skill is critical for healthcare workers and any team providing emergent care to trauma patients.

*Note that this is a general approach to the trauma patient. Always consult your care team for adequate management of trauma patients and resort to reliable resources for more information on the ABCDE approach.

References and Further Reading

Thim, T., Krarup, N. H. V., Grove, E. L., Rohde, C. V., & Løfgren, B. (2012). Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International journal of general medicine, 5, 117.
Koster, R. W., Baubin, M. A., Bossaert, L. L., Caballero, A., Cassan, P., Castrén, M., … & Sandroni, C. (2010). European Resuscitation Council Guidelines for Resuscitation 2010 Section 2. Adult basic life support and use of automated external defibrillators. Resuscitation, 81(10), 1277-1292.
Subcommittee, A. T. L. S., & International ATLS Working Group. (2013). Advanced trauma life support (ATLS®): the ninth edition. The journal of trauma and acute care surgery, 74(5), 1363-1366.
Sternbach, G. L. (2000). The Glasgow coma scale. The Journal of emergency medicine, 19(1), 67-71.

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How To Write A Manuscript

January 17, 2022December 11, 2021 ~ Arif Alper Cevik ~ Leave a comment

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 14th episode is “How to write a manuscript”

Prof Fikri Abu-Zidan - Short Bio

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Question Of The Day #72

January 14, 2022December 27, 2021 ~ Joseph Ciano, USA ~ Leave a comment

Which of the following is the most likely cause of this patient’s condition?

Explanation

This patient presents to the Emergency Department with severe agitation and altered mental status. His exam demonstrates hypertension, tachycardia, elevated temperature, restlessness, dilated pupils, and wet diaphoretic skin. Altered mental status has a broad differential diagnosis, including intracranial bleeding, stroke, post-ictal state, hypoglycemia, electrolyte abnormalities, other metabolic causes, infectious etiologies, toxicological causes, and many other conditions. This patient’s history and exam support the presence of a toxidrome. See the chart below for a review of the most common toxidromes (toxic syndromes).

This patient has a sympathomimetic toxidrome (Choice C), which can be caused from cocaine, MDMA (ecstasy), methamphetamine, and other drugs. The anticholinergic toxidrome (Choice A) has many overlapping features with the sympathomimetic toxidrome, such as elevated blood pressure and heart rate, elevated temperature, agitation, and dilated pupils. One feature that can be used to differentiate these toxidromes is the skin exam. Sympathomimetic agents commonly cause wet diaphoretic skin, while anticholinergic agents cause dry skin. The cholinergic toxidrome (Choice B) presents with increased secretions (wet skin, diarrhea, vomiting, hypersalivation, bronchorrhea, etc.). One cause of this toxidrome is exposure to organophosphates. This patient is diaphoretic, but otherwise does not possess the other features of the cholinergic toxidrome. The opioid toxidrome (Choice D) would present with somnolence, as opposed to the CNS excitation seen in this patient. Correct Answer: C

References

Christy, G. (2019). EM@3AM: Overdose. EMDocs. http://www.emdocs.net/em3am-overdose/

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Critical Appraisal Of An Article

January 10, 2022December 27, 2021 ~ Arif Alper Cevik ~ Leave a comment

The series name is FUNDAMENTALS OF RESEARCH IN MEDICINE and will include various aspects of research. We hope you will enjoy listening to the advice of Prof. Abu-Zidan.

The 13th episode is “Critical appraisal of an article”