Paramedics have generally been able to give epinephrine injections for anaphylaxis in Illinois and elsewhere. If only the Sanofi recall caused the price increase, the price would not have been increasing for the past 10 years, but only for the past 10 months. The problems with having basic EMTs giving epinephrine injections are that the education has to be very good and the oversight has to be aggressive.
The closest children’s hospital only uses autoinjectors, because they do not allow the nurses to draw up epinephrine for anaphylaxis. Senior house officers (SHOs) (n=78) at the start of their accident and emergency (A&E) post were given an anonymous five case history questionnaire, containing one case of true anaphylaxis, and asked to complete the medication they would prescribe. Despite updated guidelines, junior doctors continue to have poor knowledge about the recognition and management of anaphylaxis, with some still considering inappropriate intravenous adrenaline. With training, EMTs in the program have learned to administer epinephrine efficiently and safely, he said. The article suggests that King County is tracking their results carefully, which does not appear to be the case for EMS systems that have first responders giving naloxone. Anaphylaxis is a life-threatening presentation and requires prompt recognition and appropriate adrenaline administration. This is a very interesting trial that may surprise the many outspoken amiodarone advocates, but it should not surprise anyone who pays attention to research. ALPS showed that we should stop giving amiodarone for unwitnessed shockable cardiac arrest.
One problem with the study that they do not address on the podcast is that the patients in the study appear to have had time to watch Casablanca before treatment started. If nothing else, this demonstrates how little we need to worry about immediately pushing drugs for stable monomorphic VT (V Tach or Ventricular Tachycardia). Research shows that for stable monomorphic VT (V Tach or Ventricular Tachycardia) amiodarone is not very likely to be followed by an improvement. It does not appear as if any patient received amiodarone or procainamide until after waiting in the ED (Emergency Department) for over an hour. Intravenous amiodarone did not prevent induction of sustained ventricular tachycardia in any of five patients inducible at baseline. Sedation, search for reversible causes, apply defibrillator pads, and be prepared to cardiovert. As I discovered, the reason for this patient’s terror was that he had been cardioverted in an awake state. This study is very small (not the fault of the authors), but it adds to the evidence that amiodarone is not a good first treatment for the patient.
Kudenchuk PJ, Brown SP, Daya M, Rea T, Nichol G, Morrison LJ, Leroux B, Vaillancourt C, Wittwer L, Callaway CW, Christenson J, Egan D, Ornato JP, Weisfeldt ML, Stiell IG, Idris AH, Aufderheide TP, Dunford JV, Colella MR, Vilke GM, Brienza AM, Desvigne-Nickens P, Gray PC, Gray R, Seals N, Straight R, Dorian P; Resuscitation Outcomes Consortium Investigators. Overall, neither amiodarone nor lidocaine resulted in a significantly higher rate of survival or favorable neurologic outcome than the rate with placebo among patients with out-of-hospital cardiac arrest due to initial shock-refractory ventricular fibrillation or pulseless ventricular tachycardia.
Ortiz M, Martin A, Arribas F, Coll-Vinent B, Del Arco C, Peinado R, Almendral J; PROCAMIO Study Investigators.
Marill KA, deSouza IS, Nishijima DK, Senecal EL, Setnik GS, Stair TO, Ruskin JN, Ellinor PT. Kudenchuk PJ, Brown SP, Daya M, Rea T, Nichol G, Morrison LJ, Leroux B, Vaillancourt C, Wittwer L, Callaway CW, Christenson J, Egan D, Ornato JP, Weisfeldt ML, Stiell IG, Idris AH, Aufderheide TP, Dunford JV, Colella MR, Vilke GM, Brienza AM, Desvigne-Nickens P, Gray PC, Gray R, Seals N, Straight R, Dorian P, & Resuscitation Outcomes Consortium Investigators (2016).
Ortiz M, Martin A, Arribas F, Coll-Vinent B, Del Arco C, Peinado R, Almendral J, & PROCAMIO Study Investigators (2016).
Marill KA, deSouza IS, Nishijima DK, Senecal EL, Setnik GS, Stair TO, Ruskin JN, & Ellinor PT (2010). An elaborate placebo is a placebo that does better than a pill, or injection, apparently because the patient has more invested in the belief the placebo will work. If the essence of acupuncture is the magic of the qi points, but the same effect is produced when staying away from the qi points, the qi points aren’t doing anything. Since it is not the acupuncture, but the patient’s reaction to the ceremony of the placebo that appears to be providing the pain relief, how many different ways might we vary the treatment to improve the placebo effect? What are the ethical concerns of using placebo medicine, when the placebo appears to provide similar, but safer, relief than real medicine? Since the ED does not appear to be the source of the increase in opioid addiction, should we sacrifice any integrity in pursuit of placebo treatments? We have an epidemic of opioid addiction because of excessive prescriptions for long-term pain. Espay AJ, Norris MM, Eliassen JC, Dwivedi A, Smith MS, Banks C, Allendorfer JB, Lang AE, Fleck DE, Linke MJ, Szaflarski JP.
Cherkin DC, Sherman KJ, Avins AL, Erro JH, Ichikawa L, Barlow WE, Delaney K, Hawkes R, Hamilton L, Pressman A, Khalsa PS, Deyo RA. Grissa MH, Baccouche H, Boubaker H, Beltaief K, Bzeouich N, Fredj N, Msolli MA, Boukef R, Bouida W, Nouira S.
Filed Under: 'Alternative' Medicine, Critical Judgment, EBM, Heresy, Morphine, Pain Management, Research Blogging Is EMS a Trade or a Profession?
Backboards are rarely used in the places that have admitted that we do not have any valid evidence that backboards improve outcomes, while we do have good evidence that backboards cause harm. People are paying more attention to the evience, rather than making excuses for the absence of evidence. Many states use the NREMT (National Registry of EMTs) test to determine if a paramedic is ready to become a new hire paramedic with no experience, some day to be able to work without a supervisor present. Many of us have had discussions that became heated, because the other person would not see reason, we would not see reason, or neither of us would see reason.
Here is an article about someone who got a bit carried away with making his point and lost perspective. The following video does an excellent job of explaining why a full tank may take a while to explode.
Science, a systematic way for carefully and thoroughly observing nature and using consistent logic to evaluate results,[2] shows us that the earth is not quite flat. There is an excellent short article explaining the way science has improved our understanding of the shape of the earth. Nowadays, of course, we are taught that the flat-earth theory is wrong; that it is all wrong, terribly wrong, absolutely. Read The Relativity of Wrong and learn a bit about how science works and what it means to be wrong. Today we celebrate the fears of those who do not understand that magic does not affect reality. Other Than IEMs, What Metabolic Emergencies Can Present To The Pediatric Emergency Department? Hyperglycemia may be the most common laboratory abnormality suggestive of a metabolic emergency. Presentation of type 1 diabetes mellitus can vary between patients who are diagnosed with diabetes mellitus by screening and symptom history and those who arrive at the ED with life-threatening cerebral edema from DKA.
The emergency clinician faced with hypoglycemia in a child is challenged to balance the need to deliver timely therapy with the need to obtain the appropriate diagnostic tests. The differential diagnoses for hypoglycemia,which can be reduced to ketotic and nonketotic processes, are presented in Table 9. Bedside testing of glucose levels should be confirmed by a glucose level performed in the laboratory.
Increased serum sodium levels result in increased deep tendon reflexes, tetany or rigidity, tremulousness, and a high-pitched cry.
After febrile seizures, hyponatremia is the second most common cause of first-time seizures in children younger than 2 years.25 Acute gastrointestinal losses and improper mixing of formula leading to water intoxication are the most common causes of hyponatremia. Hypocalcemia and hypomagnesemia should be considered together as they have similar presentations: jitteriness, seizures, irritability, lethargy, poor feeding, or vomiting. Symptoms and signs should prompt a laboratory workup that includes the standard electrolyte values as well as ionized calcium, magnesium, and phosphorous levels.
Hypercalcemia deserves mention because of the rare but severe disorder known as neonatal hyperparathyroidism, an autosomal recessive condition resulting in life-threatening calcium levels.
Hyperkalemia is another medical emergency that can cause weakness and paralysis and, more important, cardiac conduction disturbances including arrhythmias and cardiac arrest. Oxygen Administration ? Guidelines ? First aid providers may administer oxygen to victims experiencing shortness of breath or chest pain. Oxygen key points ? Emphasize difference between oxygen and supplemental oxygen ? There have been no randomized, controlled trials evaluating the effectiveness of oxygen therapy for victims with shortness of breath or chest pain.
Oxygen key points ? Studies using supplemental oxygen in resuscitation have shown that the patients achieve supra-physiologic blood oxygen levels.
Patient Positioning ? Guidelines ? An unresponsive, spontaneously breathing person may be placed in any side-lying recovery position versus the supine position (option*). Allergic Reaction ? Guidelines ? First aid providers should not be expected to recognize the signs and symptoms of anaphylaxis without training and experience (recommendation**).
Allergic Reaction ? Guidelines ? Epinephrine should be given only when symptoms of anaphylaxis are present (recommendation**).
Hyperventilation ? Guidelines ? If unclear whether the victim is experiencing hyperventilation or other breathing emergency, first aid providers should treat the victim as if there is a breathing emergency. Foreign Body Airway Obstruction - 1 ? Guidelines ? Combination of back blows followed by chest compression should be used for clearance of FBAO in conscious and unconscious infants ?1 year old (recommendation**). Foreign Body Airway Obstruction - 2 ? Unconscious victims should receive chest compressions for clearance of the foreign body in adults and children >1 year old (standard***).
Poisoning ? Guidelines ? Activated charcoal should be used as a first aid measure only on the direction of a poison control centre or equivalent agency (recommendation**). Poisoning key points - 1 ? Water irrigation: ? Evidence from multiple studies examining alkali and acid exposure of both the eye and skin showed that outcomes were improved when water irrigation was rapidly administered in first aid treatment. Poisoning key points - 2 ? Dilution with milk or water: ? There are no human studies on the effect of treating oral caustic exposure with dilution therapy. Poisoning key points - 3 ? Activated Charcoal: ? The published data on experience with activated charcoal administered by first aid providers to victims of suspected poisoning is limited. Carbon monoxide ? Guidelines ? First aid providers may attempt rescue if trained and able to perform safely (option*). Chest pain ? Guidelines ? Victims experiencing chest pain must be assisted with taking their prescribed aspirin (standard***). Chest pain ? Guidelines ? The first aid provider should assist the patient with administration of his or her prescribed nitrate (recommendation**). Chest pain key points ? Evidence from two large randomized trials clearly demonstrates that administration of aspirin within the first 24 hours of onset of chest pain in patients with acute coronary syndromes reduces mortality. Dehydration key points ? Two studies have shown that oral strategies of fluid resuscitation are as effective as IV routes for people with dehydration. As mentioned previously, the causes of unconjugated hyperbilirubinemia can be best summarized as bilirubin overproduction, impaired hepatic bilirubin uptake, and impaired bilirubin conjugation. Bilirubin overproduction can result from increased breakdown of hemoglobin and other heme-containing proteins.
In the infant, ABO blood group incompatibility is a common cause of hemolysis leading to hyperbilirubinemia; however, it is most often diagnosed before the newborn is discharged from the nursery.
Impaired bilirubin uptake is associated with disorders that cause reduced hepatic blood flow (eg, heart failure, portosystemic shunt) and drugs such as rifampin and probenecid that may impair uptake of bilirubin by the liver.
Certain inherited disorders may impair bilirubin conjugation and lead to unconjugated hyperbilirubinemia. Hyperthyroidism may occasionally result in jaundice, although the cases presented have involved underlying liver disease or use of hepatotoxic medications.30 Certain drugs can also inhibit bilirubin glucuronidation. Breast milk jaundice is the persistence of physiologic jaundice beyond the first week of life in breastfed infants. In addition to the initial workup for jaundice in the ED, infants with unconjugated hyperbilirubinemia should have a complete blood cell count (CBC), a peripheral blood smear, and a Coombs test to evaluate for anemia and hemolysis. The main goal in the treatment of unconjugated hyperbilirubinemia is the prevention of kernicterus.
Etiologies of ALF vary by age, with metabolic and infectious diseases prominent in the first year of life and acetaminophen overdose and WD occurring in adolescence. Fulminant hepatic failure may also result from use of some hepatotoxic drugs and chemicals. Patients with severe ALF need to be observed for features of HE, which initially may be characterized as minor disturbances of consciousness or motor function.
The patient’s respiratory rate may be increased early, but respiratory failure may also occur during the evolution to stage IV coma. Renal dysfunction commonly occurs as a result of dehydration, acute tubular necrosis associated with the initial toxic insult, and HRS. Intravenous, subcutaneous, or intramuscular vitamin K should be given to help correct the coagulopathy (2-2.5 mg in infants, 5 mg in older children and adolescents). Gram-positive and gram-negative bacteria or fungal infections commonly occur and may be fulminant for patients with liver failure.
A variety of approaches has been used to assist the liver in removing toxins that may cause encephalopathy.
A number of liver assist devices are under evaluation: non-cell-based systems (molecular absorbent recycling systems), cell-based bioartificial liver systems, hepatocyte bioreactors, and stem cell transplantation. Acetaminophen use is the most common cause of DILI in the United States as well as the second most frequent etiology of ALF in children. The use of herbal remedies must be considered as an etiology in any setting of liver injury.
Wilson’s disease, also known as hepatolenticular degeneration, is an autosomal recessive disorder of copper metabolism.
The medical management of WD is based on the use of copper chelators (penicillamine or trientine) or zinc to reduce copper absorption. Patients with hypothyroidism or panhypopituitarism may also present with jaundice.8 Infants with a metabolic disease such as galactosemia may present with vomiting, diarrhea, lethargy, and hypotonia within hours of milk ingestion.
Caroli disease is a congenital disorder characterized by multifocal, segmental dilatation of large intrahepatic bile ducts.
Upon admission, all patients should have screening laboratory tests including amylase and lipase levels, triglyceride levels, calcium level, and liver chemistries (bilirubin, aspartate aminotransferase [AST], alanine aminotransferase [ALT], and alkaline phosphatase). For most cases of pancreatitis, treatment consists of pain relief, intravenous hydration with limitation of oral intake, and observation for complications. Diagnosis of extrahepatic biliary obstruction versus intrahepatic causes of hyperbilirubinemia can be accomplished through various imaging modalities. Bacterial infections are a well-known cause of concomitant conjugated hyperbilirubinemia, most likely due to the effect of bacterial endotoxins on bile formation.2 The most frequent bacterial organism causing neonatal hepatitis is E coli.
Infection with any of the hepatotropic viruses (A, B, C, D, or E) may cause jaundice in the pediatric population, specifically older children and adolescents.

Diagnosis: Serologic markers for anti-hepatitis A viral antigen (anti-HAV) should be sent on presentation, including anti-HAV immunoglobulin M (IgM) and anti-HAV IgG.
Treatment: Treatment of hepatitis A infections is supportive, focusing on the hydration status of patients with vomiting and fatigue. Clinical Features: Pediatric patients with hepatitis B (HBV) and hepatitis C (HCV) infections are asymptomatic. Hepatitis B: In the general population, acute HBV infections result from horizontal transmission, namely via highly infectious family members, improperly sterilized syringes, accidental needle sticks, or unprotected sexual activity.
Hepatitis C: Prior to 1992, most children contracted HCV infection through contaminated blood products.
Treatment: Hepatitis viral infections are diagnosed by serologic antibody tests, which are summarized in Table 13. Jaundice and acute hepatitis can be presenting signs in older children and adolescents infected with Epstein-Barr virus and are usually seen as part of infectious mononucleosis syndrome. The cost of the autoinjector has increased from around $100 to around $600 since 2007, when Mylan bought the EpiPen as part of a group of products from Merck.
On October 30, 2015, Sanofi recalled their Auvi-Q autoinjectors due to the possibility of dosage inaccuracies.[3] Some people are claiming that the increase in cost is due to the withdrawal of this competitor from the market, but I was able to locate two other competitors in the US, so there is competition.
As with naloxone (Narcan), doctors, nurses, and paramedics often give the drug inappropriately, so we know that there is a lot of potential for error. In the case of anaphylaxis, 100% would administer adrenaline (epinephrine) but 55% would do so by the incorrect route.
All recognised the need for adrenaline in anaphylaxis, but only 74% selected the correct intramuscular route, and 34% the correct route and dose. My anecdotal experience is that this is also a problem in the US with experienced paramedics and experienced physicians.
Junior medical staff may require more emphasis on recognition and prompt adrenaline administration in both undergraduate and in hospital training and education.
Only 29%[5] or only 25%[6] or only 15% within 20 minutes, but if we don’t mind waiting an hour it can be as much as 29%.[7] For those of you who are not good at math, that means amiodarone is about the same as doing nothing, only it comes in a syringe.
Proarrhythmia, primarily torsade de pointes (TdP), has been associated with prolongation, by intravenous amiodarone, of the QTc interval to 500 ms or greater. In the absence of information about a specific problem that is best addressed by a specific drug (amiodarone is the opposite of specific), we should avoid treatments that have such a high potential for harm.
Ventricular tachycardia had been relatively slow, he had not lost consciousness, and the physicians, in the heat of the moment, had not administered adequate anesthesia. Both work quickly and the most important obstacle to immediate treatment of a patient who suddenly deteriorates is the time to effect of sedation. Amiodarone or procainamide for the termination of sustained stable ventricular tachycardia: an historical multicenter comparison. Intravenous amiodarone for the pharmacological termination of haemodynamically-tolerated sustained ventricular tachycardia: is bolus dose amiodarone an appropriate first-line treatment? Effects of intravenous amiodarone on ventricular refractoriness, intraventricular conduction, and ventricular tachycardia induction. Low doses of intravenous epinephrine for refractory sustained monomorphic ventricular tachycardia.
An injection of a placebo (saline solution) may be more effective than a pill of real pain medicine because of the ceremony involved in giving the placebo through IV (IntraVenous) access. We have no reason to expect real acupuncture to provide more pain relief than sham acupuncture, so how should we use this information?
The most frequent adverse effect was dizziness in the morphine group (42%) and needle breakage in the acupuncture group (2%).
Ryan Radecki of Emergency Medicine Literature of Note for providing me with a copy of the paper. Bryan Bledsoe that does an excellent job of identifying many of the problems with low standards in EMS – at least if the quality of care is important.
Even more important is the evidence that manipulating the patient’s spine in order to stabilize the spine is wishful thinking that encourages us to do exactly what we claim to be trying to prevent.
Ketamine may be the best sedative, best analgesic, best agitated delirium treatment available to EMS.
Some states continue to require this babe in the woods test of outdated material as their goal for even experienced paramedics. Bryan Bledsoe, Education, Ethics, National Registry When logic fails, throw propane on the fire? This is a BLEVE (Boiling Liquid Expanding Vapor Explosion), which any first responder should be familiar with. This was not because people were stupid, or because they were intent on believing silly things.
Adrenal insufficiency, diabetes mellitus, and electrolyte disorders can also cause life-threatening illnesses.
Although isolated hyperglycemia may be seen with stress, in the presence of ketonuria and acidosis, the disorder may progress to diabetic ketoacidosis (DKA) and death if left untreated. Interestingly, other than research identifying the risk factors for cerebral edema, little has been published about the acute complications of type 1 diabetes mellitus that affect the emergency clinician. Rather than considering the broad differential diagnoses of hypoglycemia, it is prudent to "shoot first and ask questions later" by obtaining the critical sample (ie, insulin, cortisol, and growth hormone levels) before glucose is delivered; serum and urine samples for ketones should also be obtained.
Glucagon delivery will stimulate the patient to metabolize glycogen to glucose and can help with diagnosis. Further testing should be driven by information obtained from the patient history and physical examination.
Dextrose 10% in water is preferred in neonates and infants to protect their delicate vasculature, but dextrose 25% can be used for children in older age groups. Early symptoms of anorexia, agitation, disorientation, and apathy often go unrecognized until more serious symptoms appear. A handheld blood gas analyzer is preferred for obtaining the ionized calcium level in a rapid fashion. Signs of elevated calcium levels include dehydration due to calciuria, failure to thrive, constipation, hypotonicity, weakness, and irritability. Any patient with hyperkalemia should be placed on a cardiac monitor and the tracing for peaked T waves evaluated. Causes include pyloric stenosis, Bartter syndrome, renal tubular acidosis, cystic fibrosis, aminoglycoside exposure, and hypokalemic familial periodic paralysis.27 The presentation may include weakness, polyuria, ileus, tetany, diminished reflexes, and paralysis leading to respiratory failure. A factor in human breast milk is thought to increase the enterohepatic circulation and absorption of bilirubin, although the particular cause has not been identified. Testing for G6PD deficiency may be added to the workup if suspicion is high, including in infants who do not respond to phototherapy. Phototherapy is the main treatment modality and works by isomerization of bilirubin to water-soluble products that can be excreted in the urine and stool. These recommendations are summarized in Table 6.34 The patient should be admitted to a pediatric service or neonatal unit where continued therapy and monitoring are available.
It is a life-threatening condition manifested by jaundice, coagulopathy, hypoglycemia, and encephalopathy. Risk factors for drug-induced hepatotoxicity are age (very young children or adolescents), abnormal renal function, concurrent use of other hepatotoxic agents, drug interactions, and preexisting liver diseases. Galactosemia, hereditary tyrosinemia type I, mitochondrial disorders, fatty acid oxidation disorders, hereditary fructose intolerance, neonatal hemochromatosis, inborn errors of bile acid metabolism, congenital disorder of glycosylation, and other inherited metabolic disorders can all cause hepatic failure. Although extremely high serum aminotransferase activity levels are often found, the peak level does not correlate well with the severity of the illness.
Renal replacement therapy with continuous venovenous hemofiltration or dialysis may be necessary, but only liver transplantation can reverse HRS.
At least 50% of patients experience a serious disorder such as sepsis, pneumonia, peritonitis, or a urinary tract infection. Plasmapheresis and perfusion of the patient’s plasma through an ion-exchange resin or a column of charcoal have been used in several studies. These methods are used to support patients until regeneration of their liver or to bridge the gap until a suitable organ donor can be found. Acute DILI is more common and can present with a variety of injury patterns including hepatocellular, cholestatic, or a mixture of the two.54 Acute cholestatic patterns often mimic those of extrahepatic obstructive jaundice, with patients presenting with both jaundice and pruritus. From 20% to 50% of patients with CF develop liver disease, ranging in severity from asymptomatic derangement of liver function tests and focal biliary fibrosis to cirrhosis with portal hypertension and chronic liver failure.68 Features of advanced clinical liver disease are most prominent in adolescents and young adults with CF.
The carrier frequency for WD is about 1 in 150 to 180 individuals, with a prevalence of 1 in 30,000.69,70 The liver is both the site of the metabolic defect in WD and the initial target of copper toxicity.
Liver transplantation is a life-saving therapy for WD patients with fulminant liver failure, those with fulminant liver failure after discontinuing copper chelation therapy, and those with decompensated liver disease unresponsive to medical therapy. Continued galactose ingestion leads to hemolysis, jaundice, liver disease, lactic acidosis, and renal tubular acidosis. It is characterized by elevated levels of transaminases and total immunoglobulin G (IgG) and positive autoimmune markers (antinuclear antibodies, anti-smooth muscle, or antiliver-kidney microsomal antibodies). A common variant known as Caroli syndrome has been associated with congenital hepatic fibrosis. In adults, cholelithiasis, intrinsic and extrinsic tumors, primary sclerosing cholangitis (PSC), parasitic infections, lymphoma, AIDS cholangiopathy, acute and chronic pancreatitis, and strictures after invasive procedures are most common.
Typically, biliary atresia presents shortly after birth with persistent jaundice, pale stools (white to beige), and dark urine in term infants with normal birthweights.
Jaundice occurs in approximately 50% of children with the disease.79 Hemolytic disorders account for most of the cholelithiasis seen in children. Group B streptococci are rarely implicated.39 In most cases, the child will present with symptoms other than jaundice that are suspicious for infection (ie, fever, lethargy). Cholestasis with cytokine release results from decreased expression of sodium, potassium, and adenosine triphosphatase and the downregulation of transport proteins critical to bile formation.39 Other infections such as cholangitis, cholecystitis, and pancreatitis can directly obstruct the biliary tree and present with jaundice. In older children and adolescents, HAV is the most common infectious cause of acute jaundice82 and usually presents with an abrupt onset of fever, headache, anorexia, nausea, and right upper-quadrant pain. Clinical symptoms as well as biochemical abnormalities will completely resolve within 3 to 6 months and, in most patients, as early as 4 weeks.83,82 Although this approach may require additional ED visits for evaluation, hepatitis A infection does not lead to chronic hepatitis (ie, infection lasting more than 6 months). Nevertheless, jaundice may occur in older children with acute HBV infection or in those with chronic HBV or HCV infection who develop cirrhosis at an early age. During that time, the packaging has gone from a single EpiPen to two EpiPens, so that may be one part of the increase.
In the remaining cases, 10%–56% would be prepared to administer adrenaline inappropriately. 82% of junior doctors would inappropriately give adrenaline to the patient who had inhaled a foreign body (case 2).
Adrenaline was more likely to be administered if the scenario included hypotension, where the junior medical officer had previous formal resuscitation training (Advanced Paediatric Life Support) and by medical officers with more years of training.
Simulated scenarios may provide a platform to deliver this training to ultimately improve patient care. Anand Swaminathan REBELCast: The PROCAMIO Trial – IV Procainamide vs IV Amiodarone for the Acute Treatment of Stable Wide Complex Tachycardia.
Even though these poor outcomes ignore the side effects, they are the best evidence in favor of amiodarone, so what Kool-Aid are the advocates drinking? How do the MACEs (Major Adverse Cardiac Events) compare with sedation and cardioversion vs.
Although QTc prolongation occurred frequently in patients receiving intravenous amiodarone, TdP or new-onset VF occurred infrequently (less than 2%).
Although the 5 mg of intravenous diazepam had made him a bit drowsy, he felt the electric current on his chest and remembered the event clearly. Neither drug is expected to interfere with perfusion, which is the main excuse given for avoiding sedation for cardioversion.
I don’t know of any research on fire walking as a treatment for pain, but I would not be surprised if it is extremely effective.
We should know enough to not throw, or even gently place, containers of flammable material on fires, unless intending to cause an explosion.
The curvature of the earth is nearly 0 per mile, so that although the flat-earth theory is wrong, it happens to be nearly right. It is simply a systematic way for carefully and thoroughly observing nature and using consistent logic to evaluate results.
As with IEMs, these disease processes should be considered early in the course of a patient's care because prompt therapy will reduce morbidity and mortality.
Congenital adrenal hyperplasia (CAH) is the most recognized form of primary AI in children, perhaps because it is a component of many newborn screening programs. The current recommendations for the emergent care of the patient with DKA are presented in Table 8. Oral glucose should be considered for patients with hypoglycemia who are capable of protecting their airway. Intracranial hemorrhage and venous sinus thrombosis due to hypernatremia have been reported. Late symptoms include lethargy, decreased reflexes, vomiting, decreased respiratory drive, and seizures. Correction of hyponatremia should be slow (conducted over 24 hours) as long as the patient does not have life-threatening symptoms such as seizures. Secondary tests include parathyroid hormone and vitamin D metabolite measurements, as well as urine levels of calcium, phosphate, and creatinine.
More severe hyperkalemia may cause widening of the QRS segment, an increasing PR interval, a sine wave rhythm, and eventually cardiac arrest.
But in remote areas where further care is delayed or when advised to do so by a poison control centre, EMS or local equivalent, giving a diluent (milk or water) may be appropriate (option*). Risk factors for hemolysis include a family history of significant hemolytic disease, a high-risk ethnic background, early or severe jaundice, or jaundice before 24 hours of life. Patients present with mild jaundice and mild elevations of unconjugated bilirubin during times of stress, illness, or fasting.
Genetic testing may also be done for Gilbert’s or Crigler-Najjar syndrome outside the ED setting, if warranted. Fulminant hepatic failure in children is a clinical syndrome that evolves over a period of 8 weeks or less from the onset of signs and symptoms of liver disease. Viral infections are identified more frequently in infants and immunodeficient patients and include herpes simplex, human herpesvirus,6 parvovirus B19, cytomegalovirus, adeno-associated virus, varicella-zoster, enterovirus, and paramyxovirus. Drug-induced hepatotoxicity can be dose-dependent, idiosyncratic, or a synergistic reaction.
Wilson’s disease is currently the most common metabolic disorder presenting with ALF in older children and adolescents.
Bleeding from the gastrointestinal tract and easy bruising as a result of severe coagulopathy is a common finding.

In metabolic disorders, liver failure may be present with only a modest elevation in activity. Intravenous fluids should be restricted and should represent only 85% to 90% of maintenance fluids to avoid overhydration. Infusion of fresh frozen plasma (FFP), recombinant activated factor VII, or platelets may be necessary in the setting of active bleeding or in anticipation of an invasive surgical procedure rather than treating laboratory abnormalities.42 Patients can rapidly become fluid overloaded with infusions of large amounts of FFP.
Infection may present subtly with tachycardia, intestinal bleeding, reduced renal output, or changes in mental status. As mentioned previously, overdosing can be intentional or unintentional in pediatric patients. Liver diseases range from asymptomatic in patients with elevated aminotransferase levels or hepatomegaly to fulminant liver failure in others, whose only option may be liver transplantation.
Liver transplantation corrects the hepatic metabolic defects of WD and may serve to initiate normalization of extrahepatic copper metabolism. A diagnosis requires a liver biopsy to reveal interface hepatitis with predominance of plasma cells.
This autosomal recessive disease has also been associated with autosomal recessive polycystic kidney disease.
Splenomegaly is not usually a feature unless presentation is late, and it is then a sign of portal hypertension.
In those patients unable to tolerate enteral nutrition, total parental nutrition (TPN) should be given.75 Endoscopic retrograde cholangiopancreatography (ERCP) may be required if gallstones are the inciting factor. In contrast, adults presented with jaundice only 25% of the time and were more likely to report abdominal pain. Other etiologies include prolonged TPN use, ileal resection, short bowel syndrome, obesity, adolescent pregnancy, and idiopathic causes.80 Choledocholithiasis is also rare in children and most commonly occurs with biliary tract malformations (eg, choledochal cysts), hemolysis, chronic liver disease, and infection.
Hepatitis D infection is rare in the United States and occurs only in those already infected with HBV. Only 5% were able to indicate the correct route and dose of adrenaline according to Resuscitation Council guidelines (UK).
A higher percentage of the 2013 cohort indicated the correct route and dose of adrenaline in anaphylaxis than their 2002 colleagues. The important consideration is that the doctors and nurses be able to apply the defibrillator pads properly and quickly and deliver a synchronized cardioversion in less than a minute.
Most commonly, it is associated with the absence of 21-hydroxylase, an enzyme in the cholesterol metabolism cascade, and results in virilization of females, salt-wasting crisis in newborns, and hyperpigmentation. A patient with an elevated blood glucose level after trauma is clearly different from a patient with sepsis whose blood glucose level rises beyond the normal range in the ICU. The Lawson Wilkins Pediatric Endocrine Society concedes that few of the recommendations are derived from high-quality research protocols. Etiologies are presented in Table 10, but the most common cause of hypernatremia is the loss of free water from diarrhea.
If the common diagnoses mentioned above do not seem likely from the given history, serious conditions such as syndrome of inappropriate antidiuretic hormone and CAH should be considered. An electrocardiogram (ECG) should also be obtained, with ongoing cardiac monitoring available during calcium replacement. Studies should include measurements of electrolytes along with ionized calcium, serum urea nitrogen, creatinine, and parathyroid hormone levels.
In the absence of peaked T waves, hyperkalemia may be considered factitious as a result of hemolysis of the original sample. In a study of rats with acid skin burns, water irrigation within 1 minute of burn prevented any drop in tissue pH, whereas delayed irrigation allowed a progressively more significant fall in tissue pH. It typically begins after the first 3 to 5 days of life, peaks within 2 weeks after birth, and improves to normal levels over 3 to 12 weeks. In some cases of non‒A-E hepatitis, encephalopathy may occur later, often from 8 to 28 weeks after the onset of jaundice, and it may have a subfulminant course. Drugs that commonly induce an idiosyncratic toxicity include isoniazid, sodium valproate, carbamazepine, penicillin, erythromycin, tetracyclines, sulfonamides, quinolones, amiodarone, and pemoline.
The patient may become somnolent and confused or combative on arousal and eventually may become responsive only to painful stimuli. Pruritus, ascites, growth failure, digital clubbing, palmar erythema, cutaneous xanthoma, and prominent abdominal vessels suggest a chronic liver condition. Electrolyte- and glucosecontaining solutions should be administered intravenously to maintain urine output, correct electrolyte abnormalities, and prevent hypoglycemia, as the liver is the primary organ for gluconeogenesis. Many OTC drugs, especially cold remedies, contain acetaminophen, and they may unknowingly be combined with other acetaminophen-containing medications, leading to hepatotoxicity. Initial presentation may include nonspecific symptoms (anorexia, fatigue, jaundice, ascites, variceal bleeding, amenorrhea, or poor school function), and misdiagnosis and lack of appropriate treatment may lead to disease progression.
An antenatal maternal ultrasound with abnormal findings (ie, a cyst related to the porta hepatis, bile duct, or liver) is associated with about 5% of biliary atresia (cystic biliary atresia) in infants.
Prophylactic antibiotics may be considered in cases of severe acute pancreatitis with necrosis, though it remains controversial, with no standardized practice guidelines. As the cause of jaundice is most likely related to the underlying illness rather than to primary liver disease, in the acutely ill child management should be geared toward the underlying disease.2 In infants, jaundice can be an early sign of urinary tract infections in the absence of other symptoms. This has implications for training as the survey took place before the start of the A&E posting. However, a greater percentage also selected adrenaline treatment inappropriately in non-anaphylactic case scenarios. If the patient has not yet been sedated, the cardioversion should be delayed until after the patient is adequately sedated, so the intervention that depends most on time is the sedation of the patient. Other congenital forms of primary AI are Addison disease and metabolic disorders such as adrenoleukodystrophy and mitochondrial disorders. The former patient may be postprandial but could also have previously unrecognized insulin insensitivity.
If a patient is unresponsive to glucose, administration of glucagon may help to mobilize glycogen stores.
Free water should be given orally whenever possible or slowly and cautiously as a component of IV hypotonic saline solution.
However, rickets should also be considered in later onset childhood hypocalcemia, especially in breastfed African American infants. An ECG will show a shortened QT interval and perhaps a U wave; severe hypercalcemia increases the PR and QRS intervals. Hyperkalemia can result from CAH, oliguric renal failure, or extensive tissue damage due to burns or crush injuries. Based on expert opinion, this practice appears to be safe and effective, although the magnitude of the benefit is hard to estimate. If there is considerable abdominal pain, bending the hips and knees may be helpful (option*). The diagnosis of Gilbert’s syndrome is usually clinical and one of exclusion, although gene testing is available.
Breast milk jaundice is different from breastfeeding jaundice, which is caused by decreased milk intake and subsequent dehydration, with weight and fluid losses within the first 7 days of life. Toxins that induce ALF include Amanita phalloides (mushroom poisoning), herbal medicines, and carbon tetrachloride. Fulminant hepatic failure may also be associated with sepsis, vascular occlusion (Budd-Chiari syndrome and veno-occlusive disease), congestive heart failure, cyanotic congenital heart disease, obstructive lesions of the aorta, circulatory shock, heat stroke, and hemophagocytic lymphohistiocytosis. Progression to deeper stages of coma can occur over the course of a few days or even weeks, as extensor responses and decorticate posturing appear.
In addition, 10% dextrose should be administered, and blood glucose levels should be monitored hourly until stabilization. Blood cultures should be obtained with any evidence of clinical deterioration and antibiotics initiated with a clinical concern for sepsis. Diagnosis is usually based on newborn screening and positive non-glucose urine reducing substances and is further confirmed by low activity of galactose-1-phosphate uridyl transferase in RBCs. In neonates with jaundice, extrahepatic biliary atresia and choledochal cysts should be suspected.
Some patients with missed diagnosis may present with failure to thrive, hepatomegaly, ascites, and coagulopathy. Screening tests such as a urinalysis and serum b-hydroxybutyrate and hemoglobin A1c measurements may help to clarify whether the hyperglycemia is an episodic or long-term problem. Type 2 diabetes mellitus is a syndrome of insulin resistance that was previously thought to be a problem only in adults. Serum urea nitrogen, creatinine, liver function, and glucose levels should be measured in addition to a urinalysis. Patients with a history of diabetes insipidus should also be prescribed desmopressin when they present with hypernatremia. DiGeorge syndrome should be considered in a child with abnormal results on cardiac examination and the characteristic dysmorphic facies. Calcium gluconate is the replacement therapy of choice for hypocalcemia because it is gentler than calcium chloride on the veins; 200 to 500 mg of calcium gluconate may be given either as an infusion or in 4 divided doses. An elevated parathyroid hormone level despite hypercalcemia necessitates surgical consultation for parathyroidectomy, although some patients may respond to bisphosphonates. In addition to the ECG, electrolytes (including urine electrolyte), serum urea nitrogen, and creatinine should be measured and a urinalysis obtained. When there is severe hypokalemia, oral replacement should be prescribed whenever possible to reduce the possibility of a catastrophic medical error in IV potassium dosage. A more rare, hereditary form of unconjugated hyperbilirubinemia is Crigler-Najjar syndrome, an autosomal recessive disease characterized by either a complete loss or a partial deficiency of bilirubin-UDP-GT enzyme (type I and type II, respectively).
The neurologic dysfunction associated with higher grades of coma is thought to be related to the development of cerebral edema, which is related to both cytotoxic and vasogenic factors. A number of electrolyte disturbances are common, including hypokalemia, hyponatremia, hypophosphatemia, hyperammonemia, metabolic acidosis, and respiratory alkalosis.
Cerebral edema is an extremely serious complication that responds poorly to measures commonly used to treat it in the presence of other disorders. Often, laboratory tests will demonstrate elevated levels of liver enzymes and conjugated hyperbilirubinemia, along with an extremely low serum ceruloplasmin level, elevated urinary copper excretion, and an elevated serum copper concentration.
It is managed medically with a galactosefree diet.68 Presentations and diagnoses of other common metabolic diseases associated with jaundice are listed in Table 11. If it takes a while to put the pads on, that is a problem with the ability of the doctors and nurses, not a medical problem. Acquired secondary AI can also occur after damage to the hypothalamic axis as a result of direct tissue damage (eg, trauma, surgery, radiation), inflammatory processes, or tumors and infiltrative processes. The recent epidemic of obesity in children and adolescents has been accompanied by an increase in the incidence of type 2 diabetes in this group, more so in nonwhite populations with high adult rates of type 2 diabetes mellitus.
Hypocalcemia may also occur as a result of hypercalciuria, which leads to nephrolithiasis; a family history of this disorder may help with the diagnosis. Extreme caution is advised to ensure that IV potassium is given at the correct dose and over the appropriate time frame.
Renal function may be impaired as a result of tubular injury, hypovolemia, or hepatorenal syndrome (HRS). Initial management includes minimizing excessive stimulation, treating suspected sepsis, and removing sedative medications that affect mental status. Large-volume paracentesis should be reserved for those patients who experience tense ascites, respiratory compromise, or renal failure. Congenital secondary AI occurs in disorders of the hypothalamicpituitary axis such as septo-optic dysplasia. Some efforts have been made to address this situation with insulin supplementation, either subcutaneously or IV.19 Normoglycemia can be achieved, but at what cost? Hypomagnesemia occurs in infants of mothers with diabetes mellitus and in patients with increased losses from the gastrointestinal and renal tracts.
Serum acetaminophen levels after 4 hours of ingestion are useful in identifying high-risk patients but are not informative in patients in whom toxicity is secondary to long-term administration.
Adrenal insufficiency can present with a variety of symptoms, although dehydration, hypotension, hypoglycemia, and altered mental status are most common. Mechanisms for the delivery of insulin that include frequent blood glucose monitoring to detect hypoglycemic complications have proven cumbersome, even in the relatively controlled environment of the ICU.20 Intensive insulin therapy should be considered but may not be a priority.
Clinicians should also be aware of the hyperosmolar hyperglycemic state (HHS), even though it is exceedingly rare in children and adolescents.
Myelosuppression is associated with non–A-E hepatitis etiology for ALF and non-immune hemolytic anemia with WD.
Patients with primary AI may have nonspecific symptoms such as fatigue, nausea, vomiting, weight loss, and abdominal pain that mimic other conditions such as chronic regional abdominal pain or neuropsychiatric disorders including depression. Discussion of patient management with the accepting intensive care physician may be helpful when intensive insulin therapy is being considered. Patients with HHS present with coma, hyperglycemia, and hyperosmolarity in the absence of acidosis or ketosis.
This condition is poorly understood but is estimated to have a mortality rate of up to 15%.
The patient's hands, areolae, genitalia, and any scars or moles should be examined for hyperpigmentation; comparison with family members is helpful to determine if the patient's hyperpigmentation is familial. 23Therapy with IV rehydration, continuous insulin infusion, and electrolyte replacement is similar to that recommended for DKA.
In addition to electrolyte and glucose levels, adrenocorticotropic hormone (ACTH) and cortisol values should be obtained. With infants in whom CAH is likely, it is prudent to test for 17-hydroxyprogesterone, dehydroepiandrosterone, and testosterone. An ACTH stimulation test, detailed in Table 7, may be helpful to confirm the diagnosis, but this should only be performed in conjunction with an endocrinologist or intensivist.15 One exception to this rule is the patient being resuscitated because of presumed septic shock.
Some experts prefer the stress dosing of dexamethasone in normotensive patients because it does not interfere with the ACTH stimulation test.8 Ongoing debate surrounds the use of etomidate as an induction agent prior to intubation of the patient with severe sepsis or shock.
A single dose of etomidate has been associated with AI in this setting, although the drug may not be the only contributing factor.18 Strategies to combat this effect include the use of other induction agents such as ketamine or avoidance of induction or sedative agents. Testing for AI with the ACTH stimulation test in this patient population is a rational clinical decision, especially if stress dose hydrocortisone is used.

How to control blood sugar after delivery
Fasting sugar level for non diabetic ketoacidosis


  1. 16.10.2015 at 22:52:24

    Pregnant, use the pregnancy normal values and.

    Author: T_A_N_H_A
  2. 16.10.2015 at 18:37:11

    Cereals generally don't fit these for the past 3 weeks.

    Author: noqte
  3. 16.10.2015 at 21:16:51

    After delivery, especially if you're but with screening for.

    Author: SamiR
  4. 16.10.2015 at 20:54:17

    Daily basis assists your doctor.

    Author: 45345