Evaluation and management of the critically ill adult asthmatic in the emergency department setting

The role of magnesium in cardiac arrest

Cardiac arrest is a leading cause of death globally. Only 25.8% of in-hospital and 33.5% of out-of-hospital individuals who achieve spontaneous circulation following cardiac arrest survive to leave the hospital. Respiratory failure and acute coronary syndrome are the two most common etiologies of cardiac arrest. Effort has been made to improve the outcomes of individuals resuscitated from cardiac arrest. Magnesium is an ion that is critical to the function of all cells and organs. It is often overlooked in everyday clinical practice. At present, there have only been a small number of reviews discussing the role of magnesium in cardiac arrest. In this review, for the first time, we provide a comprehensive overview of magnesium research in cardiac arrest focusing on the effects of magnesium on the occurrence and prognosis of cardiac arrest, as well as in the two main diseases causing cardiac arrest, respiratory failure and acute coronary syndrome. The current findings support the view that magnesium disorder is associated with increased risk of cardiac arrest as well as respiratory failure and acute coronary syndrome.

Disorders of Calcium and Magnesium

This review will discuss the importance and homeostasis of calcium and magnesium in the human body, as well as the implications and treatment of disordered calcium and magnesium. With calcium and magnesium often considered to be the "forgotten cations" in medicine, it is our hope that this review will lead providers to evaluate for and effectively manage these electrolyte disorders in the emergency department.

VV-ECMO as bridge and safety net for successful therapeutic polypragmasy in a case of influenza-triggered near-fatal asthma

Key Clinical Message

In near-fatal asthma, the combination of ECMO therapy and isoflurane application via an intensive care ventilator with an anesthetic conservation device represents a therapeutic combination in seemingly hopeless clinical situations.

Abstract

We report a case of an adult patient with near-fatal asthma, who was implanted venovenous extracorporeal membrane oxygenation in an extern hospital before transfer to our tertiary center. After 13 days and various therapeutic approaches, including inhaled isoflurane therapy via an anesthetic-conserving device, the patient was decannulated and extubated 3 days later.

A successful extracorporeal cardiopulmonary resuscitation for severe status asthmaticus with an ultra-long cardiac arrest

The mortality of severe asthma with cardiac arrest is still close to 100% even if it is treated with conventional cardiopulmonary resuscitation (CCPR). Extracorporeal cardiopulmonary resuscitation (ECPR) has been widely accepted as an alternative method when CCPR is futile. However, the maximum "low-flow" duration has not been well defined. Here, we reported a 55-year-old male with severe asthma with cardiac arrest, who was successfully treated with ECPR after 100 min of ultra-long CCPR. He was withdrawn from extracorporeal membrane oxygenator and ventilator at 72 h and 14 days after admission respectively and was discharged without permanent neurologic sequelae. This case illustrates the critical role of ECPR as a last resort in near-fatal asthma. For such patients with bystander, starting ECPR after >60 min of CCPR can still obtain satisfactory prognoses.

Is This Your Stone? Distinguishing Phleboliths and Nephroliths on Imaging in the Emergency Department Setting

BACKGROUND

Ureteral stones are a common diagnosis in the emergency department (ED) setting, often found with computed tomography (CT). The high frequency of phleboliths can confound ureteral stone diagnosis on CT imaging.

OBJECTIVE

This article provides a narrative review of the etiological, epidemiological, and radiological distinctions between ureteral stones and phleboliths for appropriate ED diagnosis and management.

DISCUSSION

Multiple studies demonstrate phleboliths, benign calcified thrombi largely in pelvic vasculature, are found at frequencies equal to or greater than those of ureteral stones on CT imaging. The calcified foundation of phleboliths and most ureteral stones, as well as the close proximity of the distal ureters to pelvic vasculature, can cause consternation in the proper diagnosis of ureteral stones in the patient with abdominal pain. Radiological findings of circumferential ureteral soft tissue edema ("rim sign") and an irregular tapering soft tissue mass ("comet tail sign") can suggest a ureteral and phlebolith etiology, respectively. These signs demonstrate high specificity but low sensitivity, and clinicians must use history, examination, and secondary signs on imaging to differentiate ureteral stones from phleboliths.

CONCLUSIONS

Phleboliths are a common finding on CT imaging. Radiological findings of rim sign and comet tail sign may help to differentiate phleboliths and ureteral stones; however, their low sensitivity and inconsistent presentation should prompt greater reliance on other signs of ureteral obstruction to aid in diagnosis of undifferentiated pelvic calcifications.

Epinephrine (adrenaline) compared to selective beta-2-agonist in adults or children with acute asthma: a systematic review and meta-analysis

BACKGROUND

International asthma guidelines recommend against epinephrine (adrenaline) administration in acute asthma unless associated with anaphylaxis or angio-oedema. However, administration of intramuscular epinephrine in addition to nebulised selective β₂-agonist is recommended for acute severe or life-threatening asthma in many prehospital guidelines. We conducted a systematic review to determine the efficacy of epinephrine in comparison to selective β₂-agonist in acute asthma.

METHODS

We included peer-reviewed publications of randomised controlled trials (RCTs) that enrolled children or adults in any healthcare setting and compared epinephrine by any route to selective β₂-agonist by any route for an acute asthma exacerbation. The primary outcome was treatment failure, including hospitalisation, need for intubation or death.

RESULTS

Thirty-eight of 1140 studies were included. Overall quality of evidence was low. Seventeen studies contributed data on 1299 participants to the meta-analysis. There was significant statistical heterogeneity, I²=56%. The pooled Peto's OR for treatment failure with epinephrine versus selective β₂-agonist was 0.99 (0.75 to 1.32), p=0.95. There was strong evidence that recruitment age group was associated with different estimates of the odds of treatment failure; with studies recruiting adults-only having lower odds of treatment failure with epinephrine. It was not possible to determine whether epinephrine in addition to selective β₂-agonist improved outcomes.

CONCLUSION

The low-quality evidence available suggests that epinephrine and selective β₂-agonists have similar efficacy in acute asthma. There is a need for high-quality double-blind RCTs to determine whether addition of intramuscular epinephrine to inhaled or nebulised selective β₂-agonist improves outcome.

PROSPERO REGISTRATION NUMBER

CRD42017079472.

Evaluation and Management of Sternoclavicular Dislocation in the Emergency Department

BACKGROUND

Sternoclavicular dislocation (SCD) is a rare injury but can result in hemodynamic and neurovascular complications. Emergency clinicians play an integral role in the evaluation and management of these injuries.

OBJECTIVE

This article provides a narrative review of the diagnosis and management of SCD for the emergency clinician.

DISCUSSION

SCD is an infrequent injury and may be misdiagnosed in the emergency department (ED). SCDs may be anterior or posterior. Although anterior SCD is more common, posterior SCD is more dangerous with a risk of pneumothorax or injury to the subclavian artery or vein, esophagus, trachea, or brachial plexus. Most patients present with shoulder and clavicular pain and decreased active range of motion. Clinicians should assess the sternoclavicular joint in patients with shoulder symptoms and consider SCD in traumatic shoulder injuries. Plain radiographs might not identify SCD, and computed tomography is recommended for both the diagnosis of SCD and evaluation of complications. Anterior SCD can be managed in the ED with analgesia, sedation, and closed reduction. If patients with posterior SCDs display airway, hemodynamic, or vascular compromise, emergent reduction is recommended with cardiothoracic consultation. Any complicated anterior SCD, including those with fracture, and all posterior SCDs require emergent orthopedic consultation, with considerations for cardiothoracic or vascular surgery notification.

CONCLUSIONS

SCD is an uncommon orthopedic injury but may result in patient morbidity or mortality. Knowledge of SCDs can optimize emergency clinician evaluation and management of this condition.