Link To Awesome EM Quick Hits 19 Angioedema, SAH Decision Tool, Breastfeeding Myths, COVID-19 Neurology, Spider Bites, Skin Abscess Management

In this post I link to the  resource from Emergency Medicine Cases, EM Quick Hits 19 Angioedema, SAH Decision Tool, Breastfeeding Myths, COVID-19 Neurology, Spider Bites, Skin Abscess Management, [Link is to the podcast and show notes]of June 2020.

Here is the timeline for the topics with the show notes for some of the lectures.

Topics in this EM Quick Hits podcast

Anand Swaminathan on airway management in angioedema (1:15)

Management of Severe Angioedema

  • For the crashing patient with severe angioedema consider a Ketamine-Only Breathing Intubation (see KOBI), an alternative to awake intubation using dissociative dose ketamine (in a typical adult 100 mg over 30 seconds), and have a “double set up” with the neck prepared for cricothyrotomy
  • For the non-crashing patient with severe angioedema consider an awake intubationwith full topicalization and fiberoptic intubation
  • Medications for ACEi-associated angioedema such as icatibant, C1 esterase inhibitors and FFP are not evidence based and are generally not indicated
  • Consider tranexamic acid (TXA) 1g IV over 10 minutes based on a study of 33 patients in France

Episode 127 – Drugs that work and drugs that don’t – Is there any role for icatibant, C1 esterase inhibitors or FFP for angioedema?

 Jeff Perry on Ottawa subarachnoid hemorrhage rule and 6hr CT rule (8:42)

Ottawa Subarachnoid Hemorrhage Rule and 6-Hour Computed Tomography Rule

The Ottawa SAH rule is recommended to assess whether or not a patient who presents with headache can be safely ruled out without any investigations.

Inclusion: GCS 15,  ≥15 years old, new severe atraumatic headache, maximum intensity within 1 hour.

Exclusion: Patients with new neurologic deficits, prior aneurysm, prior SAH, known brain tumors, or chronic recurrent headaches (≥3 headaches of the same character and intensity for >6 months).

    • Age ≥40,
    • Neck pain or stiffness,
    • Witnessed loss of consciousness,
    • Onset during exertion,
    • Thunderclap headache (peaking pain within 1 second),
    • Limited neck flexion on examination

The Ottawa SAH rule was shown to have a 100% sensitivity for SAH in its validation, however it was 95% sensitive in the latest implementation study (note that there was only one true SAH miss in this study of a patient with profound anemia)

The Ottawa SAH 6-Hour Computed Tomography Rule is recommended to assess whether or not a patient who fails the Ottawa SAH rule can be ruled out with a plain CT done within 6hrs of headache onset without the need for further investigations (lumbar puncture, CTA).

    • Exclusion: 3 or more previous similar headaches (ie, same intensity/character as their current headache) over a period of >6 months (eg, established migraines), confirmed SAH before arrival at study ED, previously investigated with CT and LP for the same headache, papilledema, new focal neurological deficit, previous diagnosis of intracranial aneurysm or SAH, known brain neoplasm, cerebroventricular shunt, headache within 72 hours following a LP, headache described as gradual or peak intensity beyond 1 hour
    • Sensitivity = 95%, specificity=100%
    • The 6-hour-CT rule resulted in a 13% decrease in LP utilization following a normal early CT (26% vs 39%)
    • 5 patients had SAH with the CT reported as normal: two unruptured aneurysms on CTA and presumed traumatic LP (as deemed by the treating neurosurgeon), one missed by the radiologist on the initial interpretation, one dural vein fistula (ie, non-aneurysmal), and one patient with sickle cell anemia with profound anemia (Hb, 63 g/L) with a 3 mm aneurysm
    • The Ottawa SAH 6hr rule for CT rule out should not be applied to patients who are known to be anemic with a serum Hb<90 g/L (9g/dL) at the time of the CT head because any blood will appear darker than usual on the CT scan making it more difficult to distinguish blood from brain tissue and hence can be missed on the CT.

The Ottawa Subarachnoid Hemorrhage decision tool on MDcalc

SGEM with Rory Spiegel deep dive into 2020 implementation study

Ottawa Rules app video

Hania Bielawskaon ED breastfeeding myths and misconceptions (21:16)

Dr. Bielawska refers us to Drugs and Lactation Database (LactMed)
Bethesda (MD): National Library of Medicine (US); 2006-.
Copyright and Permissions:

“The LactMed® database contains information on drugs and other chemicals to which breastfeeding mothers may be exposed. It includes information on the levels of such substances in breast milk and infant blood, and the possible adverse effects in the nursing infant. Suggested therapeutic alternatives to those drugs are provided, where appropriate. All data are derived from the scientific literature and fully referenced. A peer review panel reviews the data to assure scientific validity and currency.”

Rachel Bridwell, Brit Long & Michael Gottlieb on neurologic associations with COVID-19 (29:53)

Justin Hensley on management of spider bites (36:06)

Hans Rosenberg & Heather Murray on management of skin abscesses (44:52)


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