Short vs. Standard Course Outpatient Antibiotic Therapy for CAP in Children

• Clinical Question: Is a 5-day strategy of antibiotics superior to a 10-day strategy for the treatment of non-severe pneumonia in young children demonstrating early clinical response?
• Research Design: Randomized double-blind placebo-controlled superiority trial
  • Superiority trial = aims to show one treatment is clinically better than another
  • Non-inferiority trial = aims to show one treatment is not worse than active control tx
  • Intention to treat analysis = all participants who are randomized are included in the statistical analysis and analyzed according to the group they were originally assigned, regardless of what treatment (if any) they received
• Population: Eight US sites either outpatient clinic, urgent care, or ED
  • Inclusion: Children 6-71 months, diagnosed with uncomplicated CAP, prescribed with amoxicillin, amoxicillin-clavulanate, or cefdinir (IDSA recs), parental report of improvement (no fever, no tachypnea, no severe cough) by days 3-6
  • Exclusion: treatment with antibiotic before diagnosis of CAP, treatment outside of above antibiotic regimen, presence of severe CAP (significant pleural effusion, abscess, empyema, etc.), prior hospitalization during days 1-5 for CAP, history of pneumonia within past 6 months, history of asthma, history of underlying chronic medical condition
• Intervention: Short course antibiotic therapy -> 5 days antibiotics then 5 days of matching placebo  
• Control: Standard course antibiotic therapy -> 10 total days of prescribed antibiotic
• Primary Outcome: Response Adjusted for Duration of Antibiotic Risk (RADAR) measured at first outcome visit (OAV1) on days 6-10
  • RADAR determined by desirability of outcome ranking (DOOR) and ranked participants’ overall experiences
    • DOOR components: adequate clinical response, resolution of symptoms, presence and severity of antibiotic associated adverse effects
  • DOOR/RADAR helps assess the risks and benefits of new strategies to optimize antibiotic use
• Secondary Outcome: RADAR at OAV2 on days 19-25, antibiotic associated adverse effects, quantification of antibiotic resistance genes (sub-study)
• Results: 390 patients assessed, 385 patients enrolled (192 in short course and 193 in standard)
  • . Estimated probability of a more desirable RADAR for the short-course strategy of 0.69 (95% CI, 0.63-0.75)
  • RADAR at OAV2 clinically significant. The probability of a more desirable RADAR in the short-course strategy was 0.63 (95% CI, 0.57-0.69)
  • Antibiotic resistance genes were significantly lower in 5-day course than 10 days
• Conclusion: Shorter courses of antibiotics are superior in treating healthy, clinically improving children diagnosed with uncomplicated CAP
• Strengths: Clinically relevant patient-centered question, multicenter RCT so increases generalizability, placebo and antibiotics were matched for taste and appearance
• Limitations: Studied population is likely a convenience sample with selection bias (only 390 patients in 8 cities over 3 years), strict exclusion criteria, no standard definition or diagnostic criteria for CAP in this trial (viral pneumonia?), no information on diagnostic or radiographic testing (imbalanced testing frequency or imbalanced test results)

ED vs. OR Intubation of Patients Undergoing Hemorrhage Control Surgery

• Clinical Question: Does ED intubation increase the risk of death and major complication for patients undergoing urgent hemorrhage control surgery?
• Research Design: Retrospective cohort study
  • Cohort Study = outcome or disease-free study population is first identified by the exposure or event of interest and followed in time until the disease or outcome of interest occurs
• Population: National Trauma Data Bank
  • Inclusion: 16 years or older, underwent hemorrhage control surgery (received 1u blood in first 4 hours of arrival) at level 1 or 2 trauma centers, to the OR within 60 minutes of hospital arrival
  • Exclusion: suffered pre-hospital cardiac arrest, dead on arrival, non-survivable injuries, underwent ED thoracotomy, suffered severe head/face/neck injuries, presented with GCS <8, centers that performed <10 hemorrhage control surgeries
• Exposure: Endotracheal intubation performed in the ED
• Primary Outcome: in hospital mortality
• Secondary Outcome: total ED dwell time, units of blood transfused in the first 4 hours, major complications (in hospital cardiac arrest, AKI, ARDS, VAPs, severe sepsis)
• Results: 9,667 patients who underwent urgent hemorrhage control surgery at 253 levels 1 or 2 trauma centers in US/Canada
  • Most common procedure was laparotomy (68%), extremity (15%), and thoracotomy (6%)
  • ED intubation was performed in 1,972 patients (20%) and 877 (9%) died
  • • Also associated with longer ED dwell time, greater blood transfusion in first 4 hours, and higher risk of major complications (specifically inpatient cardiac arrest)
  • ED intubations significantly more likely to occur in blunt trauma with higher ISS because of severe injuries to the chest and extremities
  • Low ED intubation hospitals were significant more likely to be level 1, university affiliated trauma centers that perform higher levels of hemorrhage control surgery
• Conclusion: In patients who underwent urgent hemorrhage control at levels 1 and 2 trauma centers, ED intubation was associated with increased odds of mortality and major complications, specifically inpatient cardiac arrest
• Strengths: clinically relevant question, large patient population from multiple centers, reduced confounders by excluding patients with clear clinical indications for intubation such as those that were performed were more likely to be guided by physician discretion
• Weaknesses: reliability of some variables used in the study cannot be confirmed from the database, event-level information not available (may be other clinical indicators associated with mortality), timing of complications is unknown (no temporal association between intubation and cardiac arrest), not all hospitals have the same resources or protocols to maximize patient outcomes

7-19-23 Conference Notes

• Healthcare Quality and Safety Intro
  • Make sure you introduce yourself to patients
  • Ask “why” 5 times if you see something you want to improve – root cause analysis
  • Lean: removal of waste with an emphasis on work flow
  • Six-Sigma: eliminate defects and reduce variations in processes
• Traumacology: RSI and Pain Management
  • Intubation methods: RSI, delayed sequence (sedative first and then paralytic after appropriate oxygenation), drug assisted (sedative-only intubation)
  • RSI goals: facilitate first pass success, minimize aspiration
  • Pre-med: lidocaine (1.5mg/kg), fentanyl (2-3mcg/kg), atropine (0.02mg/kg), versed (2-4mg)
    • Lidocaine and fentanyl prevent increase in ICP by preventing cough/pain response
    • Atropine prevents bradycardia during airway manipulation (vagal response)
  • Etomidate: 0.3mg/kg (0.2mg/kg if >120kg). Adverse effects include myoclonus and protentional adrenal suppression
  • Ketamine: 1-2mg/kg. Adverse effects include tachycardia, hypertension, emesis, emergence reaction
  • Propofol: 1-1.5mg/kg. No analgesia. Adverse effects include hypotension
  • Succinylcholine: 1-2mg/kg. Adverse events include bradycardia, hypotension, hyperkalemia (severe burns >5 days old, crush injury, demyelinating disease, myasthenia gravis
  • Rocuronium: 0.6-1.2mg/kg. Emphasize higher dosing for faster onset. Duration 30-45mins
  • Vecuronium: 0.08-1mg/kg. Duration 30-60mins. Adverse events include prolonged action in hypothermia
  • Fentanyl 75-100x more potent than morphine, less histamine release
  • 1mg dilaudid is equivalent to 7mg morphine
• Transfer of Care
  • Consider EMTALA
    • Provide all patients with a medical screening examination
      • Helps uncover whether an emergency medical condition exists
    • Stabilize patients with an emergency medical condition
      • Make sure they can be transferred or discharged without clinical deterioration
    • Transfer or accept appropriate patients as needed
      • Transferring hospital should stabilize the patient to its fullest extent, provide care in route, contact the receiving hospital, and transfer the patient with copies of the medical records
• Tube Thoracostomy Simulation
  • Indications: pneumothorax, hemothorax, pleural effusion, empyemaRelative contraindications: pulmonary adhesions, coagulopathyPlacement: 4^th or 5^th intercostal space anterior to mid-axillary line above the rib to avoid the neurovascular bundle
  • Consider antibiotics (cefazolin most commonly) for infection prophylaxis

If you have the urge to order Mag for a patient, follow your intuition. But Mag might be even more important when replacing potassium.

When treating hypoK+, if the patient has an IV or will have one, I just order Mag 2g IV rapid infusion (never need to do it slowly, 20 minutes is great) along with 60meq oral K. If they are below 2.0 K+, I either give 2 K runs or if they need/can tolerate volume, a liter of D51/2NS with 20meqK (K runs which are painful and seem to take forever to get to the bedside). Of note, people with CHF very often Mag depleted from diuretics and other etiology.

If you give the Mag IV and K po a the same time, Mag is hitting them first. Tough ones are when you don’t have an IV, because Mag oxide is trash. Sometimes I still order it. But people with no IV are likely not very sick and probably have K above 3.

Something might happen when K gets below 3. So if below 3, I usually give some IV, some po.

Dr Harmon asked me about this before she graduated, and I went looking for a few papers on it. I did a little lit search and cant find a true RCT of K repletion VS K repletion WITH or AFTER Mag repletion. It would be expensive to do and lots of confounders and no one wants to spend $ on a Mag study because it’s an old, cheap medication. **(Although some press coverage now on a Magnesium L-Threonate [which I take] study that showed cognitive benefit in Alzheimers patients).

In the few relevant papers I found, authors just generally recommend Mag with K. But we should always be careful when doing something that is logical but isn’t proven empirically. Sometimes things that make sense in theory don’t pan out in studies (vitamin C in sepsis).

One study in ICU patients compared those getting lots of Mag vs those getting none, and looked at their K balance. They found an obvious benefit to Mag repletion for K balance. They cite lots of basic science research on the K-Mg interplay.

At the end of the day, most people are Mg deficient and people with low K maybe even more likely Mg deficient. Mag is awesome, no downside, patient might flush or get sleepy. Just watch out in those with renal failure.

• Not so e(FAST)
  • Do not bias yourself against doing an eFAST (especially if intoxicated and concerned for blunt trauma)
  • Novice scanners need around 600mL blood for FAST to be positive
  • Serial FAST can increase the sensitivity of the exam and decrease false negatives by 50%
  • Head injury and mild abdominal pain are associated with false negative FAST (be cautious with your FAST conclusions)
  • Caudal tip of the liver is the most common location for free fluid on RUQ view
  • A-lines originating from peritoneal stripes are suggestive of pneumoperitoneum
• Intro to Peds ED
  • “Peds ED T” lists of all ED order setsPrioritize PICU -> general floor -> discharge notes.edhighacuitytemplate and .edlowacuitytemplate are the pre-organized notes for residents.admitresidentnotification is the phrase for TigerText in note
  • Louisvillepemresources.wordpress.com
• Basics of EMS
  • Types of Providers
    • EMR (BLS): operate an emergency vehicle, BVM, OPA/NPA, Narcan, tourniquet, oxygen, CPR and AED
      • Not used in Jefferson County
    • EMT-B (BLS): 56 hours, Igels and LMAs, CPAP and BiPAP, blood glucose, EKG acquisition, LUCAS device, cannot start IV, can give ASA, glucose, IM epi, albuterol, Tylenol, ibuprofen
    • EMT-A (ALS): 228 hours, can start peripheral IV and IOs, can give D50, code dose IV epi, fentanyl, morphine, ketamine, nitro, zofran
    • Paramedic (ALS): 11 mo to 2 yrs, intubation, needle chest decompression, cricothyrotomy, interpret EKG, cardioversion, cardiac pacing, many drugs
      • None of the Jefferson County services have paralytics for RSI
  • Louisville Metro EMS and St. Matthews – Raymond Orthober, MD
  • Anchorage/Middletown EMS – Tim Price, MD
    • Uses Heads Up CPR, levophed for post ROSC, droperidol
  • Fern Creek EMS – Jeff Thurman, MD
  • Okolona EMS – Evan Kuhl, MD
  • Pleasure Ridge Park EMS – Dan O’Brien, MD
  • Patients can only decline transport if alert and oriented, not intoxicated, and decisional
  • Criteria to cease resuscitation: unresponsive, apnea, absence of palpable pulse at carotid, bilateral fixed and dilated, asystole in 2 leads (except in trauma or DNR)
    • Think twice before ceasing efforts for PEA in the field

• Room 9
  • Generally for “unstable” patients
  • Specific considerations
    • Trauma -> will need a man scan, intoxicated and difficult exam, open fractures
    • Stroke -> 10-minute goal door to CT time
    • Medical – > hypotension, hypoxia, AMS, seizure, shock
    • Sedations, procedures, cardioversion, etc.
  • PGY-1 roles
    • Help transfer from EMS stretcher to bed
    • ABCs, Exposure, Blankets
    • FAST exam -> use the barcode scanner, save clips, END EXAM, clean probe with grey wipe, interpret and sign in Qpath, /bedsideultrasound pulls interpretation into note
      • If penetrating, then start with cardiac view
      • If blunt, then start with RUQ view
  • PGY-2 and PGY-3 roles
    • Consider am I comfortable waiting several hours for their workup to start resulting?
    • Who to keep (trauma) -> man scan?, trustable exam?, vital sign derangements?, fracture/dislocation needing intervention?, elderly fall on thinner and isolated GSW to the extremities are common rollouts but do a thorough exam first
    • Who to keep (medical) -> hypotension, hypoxia, most respiratory intervention, intubated transfer patients are common rollouts
    • Who to keep (stroke) -> mostly keep all of these unless outside of window (>24 hours)
      • Get their last known normal, SBP, glucose, neuro exam, then call stroke attending
    • Level 1 criteria: confirmed SBP <90, respiratory compromise, blood products in route, GSW to the “box”, GCS <9 due to trauma, Emergency Physician discretion
      • Know the gender! Women receive O- blood. Men receive O+ blood
  • Room 9 Bay 1 -> has the most space, rigid stylet for VL intubations
  • Room 9 Bay 3 -> has chest tube and difficult airway cart
• Buprenorphine in the ED
  • Removal of X-waiver this past year via the MATE Act 2023
  • Opioids -> synthetic in nature like fentanyl
  • Opiates -> derived from poppy so opium, morphine, and codeine
  • Heroin synthesized in 1874 and thought to be safe and less addictive than morphine
  • Methadone
    • Invented in the 1940s and was created to help with opium and morphine shortage
    • Full opioid agonist. Started being used as maintenance therapy. Dispensed as a daily medication because it is a schedule two drug not covered under original DATA legislation, unlike suboxone which is a schedule three drug and is covered
    • Causes prolonged QT. End of T wave finishes greater than ½ the RR interval
  • Opiate Use Disorder (OUD)
    • Specific criteria from DSM-5
    • Withdrawal timeline: symptom peak at 72 hours (nausea/vomiting/diarrhea, etc.)
      • Start suboxone while they are already in withdrawal
      • Use the COWS score to grade withdrawal symptoms
        • Less than 13 is mild, 13-24 is moderate, 25-36 moderately severe, more than 36 is severe withdrawal
  • Buprenorphine
    • Partial agonist for the mu receptor
    • Ceiling effect for pain control, respiratory depression with minimal euphoria
    • Cannot be injected IV (due to naloxone)
    • Minimal side effects and contraindications (acute liver failure)
    • 2% bioavailability of naloxone when taken sublingually, so does not affect buprenorphine absorption
    • Trying to use opioids after taking suboxone is not particularly effective because buprenorphine is saturating receptors
  • Other MAT options
    • Buprenorphine/Naloxone (Suboxone)
    • Buprenorphine (Subutex)
    • Long-acting Naltrexone IM (Vivitrol)
    • Long-acting buprenorphine SQ (Sublocade)
  • Supportive Care for Opioid Withdrawal
    • Ibuprofen or Toradol (pain)
    • Loperamide (diarrhea), Bentyl (abdominal cramps), Zofran (nausea)
    • Clonidine (anxiety/tremors)
  • What dose???
    • Comes in 8mg (buprenorphine)/2mg (naloxone) and 2mg (buprenorphine)/0.5mg (naloxone)
    • Try to start with 8mg on day one, 16mg (8mg BID) day two, etc.
    • Can start at COWS of 8 (with objective signs) or 12 without
    • Can always start with test dose of 2mg. If they get worse, then likely used opioids more recently than they say or withdrawal is not severe enough. If they get better, then safe for higher dose
    • Precipitated withdrawal -> can either do supportive care or give higher doses of suboxone
• Air Methods
  • Benefits of an air ambulance -> saves time (most benefit when ground time is >1 hr), ability to give blood products, preserves “golden hour” of resuscitation
  • Tools: blood, antibiotics, RSI, TXA, tube thoracostomy, push dose pressors, dual providers
  • Other circumstances: GCS <8, dissecting AA, already on ECMO, LVADs, prone patients (think ARDS), IABP, organ transplant
  • Considerations: weight restrictions, cardiac arrest, combative patient, weather, decon
• Chaplaincy Services
  • Bad news: any news that adversely and negatively impacts their view of life
  • Basic steps
    • Gather information
    • Provide information
    • Support patient/family
    • Develop a strategy for treatment and care
  • SPIKES also a good mnemonic for breaking bad news, but meant for oncology patients
    • Setting (secure a quiet location)
    • Perception (determine what patient/family already knows)
    • Invitation (clarify information preferences)
    • Knowledge (give the information)
    • Empathy (respond to emotion)
    • Summary (next steps and follow up plan)