A literature-based algorithm for the treatment of children with radial head subluxation who fail to respond to initial hyperpronation
Correspondence / American Journal of Emergency Medicine 35 (2017) 1363-1382 1365
Table 2
Naloxone utilization by JMH ED (a) frequency table indicating a larger usage of 2 mL nal- oxone vials by JMH ED in 2016 (b) One-way ANOVA results demonstrating a statistically significant difference in the mean utilization of naloxone by JMH ED between July-Sep- tember 2015-16.
Naloxone utilization by JMH ED a
2015 2016 % change
July 92 217 136
August 65 436 571
References
- Substance Abuse and Mental Health Services Administration. Results from the 2013 national survey on drug use and health: summary of national findings. NSDUH Ser H-48, HHS Publ No 14-4863. Rockville, MD: Subst Abus Ment Heal Serv Adm.; 2014 1-143[doi:NSDUH Series H-41, HHS Publication No. (SMA) 11-4658].
- Centers for Disease Control and Prevention. Synthetic opioid data. Available from: https://www.cdc.gov/drugoverdose/data/fentanyl.html. [Accessed February 3, 2017].
- National Center for Biotechnology Information. Carfentanil C24H30N2O3. PubChem Compd Database.:CID=62156. Available from: https://pubchem.ncbi.nlm.nih.gov/ compound/62156. [Accessed October 11, 2016].
- Kreeger TJ, Arnemo JMR. Handbook of wildlife chemical immobilization. Fort Collins, Colorado: Wildlife Pharmaceuticals Inc.; 2002.
Source SS Df MS F P
Mean naloxone utilization 169,680.1667 1 169,680.1667 10.67 0.030891
July-Sept 2015-16
Within group 63,594.6667 4 15,898.6667
but heroin with a stronger opioid receptor agonist additive such as a synthetic opioid like fentanyl.
The CDC released a statement in August of 2016 indicating that the presence of fentanyl and its analogs can be anticipated when traditional naloxone dosing protocols are ineffective [5,6,7]. Their statement sup- ports the suggestion that increased naloxone dosing can be an indirect indicator of FLH. Furthermore, a large influx of FLH was documented in the Midwest around the same time as the Miami OOD increase [8]. Due to its temporal association, the Midwestern FLH influx may have spread to adjacent regions and down into the Southeast.
In Miami as well as elsewhere, First responders should be educated on the presence of FLH and adjust their dosing protocols to effectively reverse overdose [6,7]. Intervention strategies at the level of the ED and community should aim to increase the availability of naloxone to users in order reverse overdose earlier and prevent the accelerated onset of respiratory depression seen with FLH. harm reduction strategies should be implemented so com- munity users and drug dealers can adjust their dosage to avoid overdosing. Our nation is amid a heroin crisis that continues to morph and create new public health challenges. Epidemiological studies are vital for bet- ter understanding of how the heroin crisis is uniquely impacting our communities. Only through such research can we effectively utilize our precious public health resources to decrease the morbidity and mor-
tality associated with contemporary Heroin use.
Due to the nature of our study we cannot factually conclude that FLH drove our local spike in OOD. However, emerging public health issues often manifest first in the emergency department [9,10].
Alexander Diaz Bode*
Mallika Singh James Andrews
University of Miami Leonard M. Miller School of Medicine, 1600 NW10th
Ave #1140, Miami, FL 33136, United States
*Corresponding author at: University of Miami Leonard M. Miller School of Medicine,1600 NW 10th Ave #1140, Miami, FL 33136,
United States. E-mail address: [email protected] (A.D. Bode), [email protected] (M. Singh), [email protected] (J. Andrews)
Girish B. Kapur Amado Alejandro Baez
Jackson Memorial Hospital Department of Emergency Medicine 1611 NW 12th Ave, Miami, FL 33136, United States
E-mail addresses: [email protected] (G.D. Kapur)
[email protected] (A.A. Baez) http://dx.doi.org/10.1016/j.ajem.2017.02.043
Network HA. Network HA. This is an official CDC health update. System. 2008; 26(Figure 1):4-7.
- Sanburn J. Heroin is being laced with a terrifying new substance: what to know about carfentanil. Time 2016. http://time.com/4485792/heroin-carfentanil-drugs- ohio/. [Accessed February 3, 2017].
- Grudzen CR, Anderson JR, Carpenter CR, Hess EP. The 2016 academic emergency medicine consensus conference, shared decision making in the emergency depart- ment: development of a policy-relevant patient-centered research agenda May 10, 2016, New Orleans, LA. Acad Emerg Med 2016;23(12):1313-9. http://dx.doi.org/ 10.1111/acem.13047.
- Nelson J, Venkat A, Davenport M. Responding to the refusal of care in the emergency department. Narrat Inq Bioeth 2014;4(1):75-80. http://dx.doi.org/10.1353/nib. 2014.0008.
A literature-based algorithm for the treatment of children with radial head subluxation who fail to respond to initial hyperpronation
We are grateful to Bexkens et al. for their excellent systematic re- view of reduction maneuvers for radial head subluxation [1]. In demon- strating the superiority of hyperpronation (HP) compared to supination-flexion (SF) (90.8% vs 72.6%; Number Needed to Treat, 5.5), their study is sure to be of great help to practicing clinicians. De- spite its excellent success rates, HP still fails to reduce a Nursemaid’s elbow about 10% of the time. What then? Though Bexkens et al. did not address this question directly in their review, their identification of the trial literature on this topic set the stage for our review of these same trials with this question in mind: what sequence of steps does the literature suggest as a reasonable approach to the patient who fails to respond to initial HP?
The systematic review included 701 patients from seven random- ized control trials from 1998 to 2016 that compared HP to SF for first-at- tempt reduction success [1-8]. No uniform protocol was followed across these trials for what steps to take if the initial attempt was unsuccessful. The trials each had their own algorithm. We catalog these in Table 1. Variations are seen across the board, including the pre-procedural posi- tioning of the elbow, the nature of the second maneuver (a repeat of the first, or a trial of the alternate procedure), the time interval between maneuvers (ranging from 10 min to 30 min), and the number of at- tempts undertaken before obtaining radiographs (ranging from three to four).
Despite the lack of uniformity, some approaches were more com- monly employed. Of the five trials that indicated the position of the elbow at the time of initial HP, four started with the elbow flexed be- tween 70 and 90 degrees (Table 1). Six of the seven performed simple HP, whereas one followed HP immediately with flexion. Five of seven trials adopted HP as their second maneuver, whereas two switched to SF. The rates of success, however, were comparable: HP (16/25; 65%) vs SF (5/7; 71%). Of the six studies that reported a third maneuver, all switched to the technique that alternated with their second maneuver. Six trials reported the time intervals between procedures: three waited 10 min, two waited 15 min, and one observed their children for 30 min before the next attempt. Though one trial reported only the first two
1366 Correspondence / American Journal of Emergency Medicine 35 (2017) 1363-1382
Table 1
Sequence of maneuvers and their success rates in trials of reduction techniques for presumed radial head subluxation. Trial’s first author Maneuver (elbow position)a [success n/total n]
1st attempt
2nd attempt
3rd attempt
4th attempt
HP (90?) [39/41]
HP (90?) [1/2]
Sup (90?), then flexion [0/1]
Sup (90?),
then flexion [0/1]
Sup (90?), then flexion [34/44]
Sup (90?), then flexion [4/10]
HP (90?) [5/6]
HP (90?) [1/1]
McDonald et al. [3]
HP (NR), then flexion [53/67]
HP (NR), then flexion [9/14]
Sup (NR), then flexion [3/5]
-
Sup (NR), then flexion [47/68]
Sup (NR), then flexion [4/21]
HP (NR), then flexion [13/17]
-
Green et al. [4]
HP (NR) [32/35]
Sup (NR), then flexion [31/37]
Sup (NR), then flexion [3/3] HP (NR) [4/6]
Not needed
NRc
-
-
Bek et al. [5]
HP (90?) [32/34]
HP (90?) [2/2]
Not needed
-
Sup (90?), then flexion [22/32]
Sup (90?), then flexion [7/10]
HP (90?) [3/3]
-
Gunaydin et al. [6]
HP (90?) [65/68]
HP (90?) [1/3]
Sup (90?), then flexion [2/2]
-
Sup (90?), then flexion [56/82]
HP (70-90?) [61/65]
Sup (90?), then flexion [1/26]
Sup (90?) with simultaneous flexion [2/4]
HP (90?) [25/25]
HP (70-90?) [1/2]
-
-
Sup (90?) with simultaneous
HP (70-90?) [8/10]
Sup (90?) with simultaneous
-
flexion [40/50] HP (NR) [36/40]
HP (NR) [3/4]
flexion [0/2]
Sup (NR), then flexion [0/1]
-
Sup (NR), then flexion [25/38]
Sup (NR), then flexion [7/13]
HP (NR) [0/6]
-
HP, hyperpronation at the wrist; Sup, supination at the wrist; NR, not reported.
a Elbow position at the time of maneuver is reported in degrees of flexion.
b Five patients who failed to respond to the series of three maneuvers were found to have fractures. These are not included in this cohort of 85 patients.
c The third maneuver was outside the study protocol and left to the discretion of treating physician.
d Unlike the other trials, enrolled patients in this study may have failed repeat Reduction attempts in other clinical settings before study enrollment.
e Elbow position at time of maneuver is not specified in the text, but implied by a figure to be in only slight flexion.
attempts and another specified a full four attempts, five of the seven prescribed three attempts before obtaining radiographs. Imaging was uncommonly needed, however, as most children achieved elbow reduc- tion by the time of study completion (approximately 97%) (Table 1). If imaging was negative, children who failed to recover their normal ac- tive range of motion in most trials had their elbow immobilized and were provided close outpatient follow-up.
Using this trial evidence as a guide to the treatment of children with presumed radial head subluxation, we propose the following approach. HP should be the initial maneuver with the elbow positioned between 70 and 90 degrees of flexion [1]. Up to three attempts can be pursued if needed, each separated by 10-15 min. Either HP or SF can be employed for the second maneuver, followed by the alternate for the third maneuver. Children who fail to regain normal elbow function after three reduction attempts should undergo radiographic evaluation.
Fig. 1. An algorithmic approach to Nursemaid’s elbow reduction derived from trial data. HP, hyperpronation; SF, supination with flexion. a. If SF was performed for the second maneuver, undertake HP for the third; and vice versa, if HP was performed for the second maneuver, undertake SF for the third.
If the elbow x-rays are negative, it seems prudent to immobilize the arm and arrange close outpatient follow-up.
Some children in these trials who had failed to respond to initial HP required a combination of maneuvers-HP plus SF-to finally achieve re- duction. Though these trials separated the two maneuvers in time, we are curious about their performance in quick succession: HP followed immediately by SF as one integrated procedure. We have not seen this two-step combination subjected to formal study, but think it worth investigating.
We summarize in Fig. 1 our approach to the child with presumed ra- dial head subluxation. The suggestions beyond initial HP are not hard and fast, nor are they solidly evidence-based. But they are reasonable and emerge from the trial data as sensible steps to follow in the 10% of children whose Nursemaid’s elbow needs something more than initial HP.
Corby W. Makin, DO
Department of Emergency Medicine University of California Davis Health Systems, United States
David R. Vinson, MD
The Permanente medical group, Kaiser Permanente Division of Research,
Oakland, CA, United States CREST Network, Oakland, CA, United States
Department of Emergency Medicine, Kaiser Permanente Sacramento
Medical Center Sacramento, CA, United States Volunteer Clinical Faculty, Department of Emergency Medicine, University
of California Davis Health Systems, United States
Corresponding author at: 455 First Avenue, Room 123
New York, NY 10016, United States
E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2017.03.003
Bexkens R, Washburn FJ, Eygendaal D, van den Bekerom MP, Oh LS. Effectiveness of reduction maneuvers in the treatment of nursemaid’s elbow: a systematic review and meta-analysis. Am J Emerg Med 2017;35(1):159-63.
- Macias CG, Bothner J, Wiebe R. A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations. Pediatrics 1998;102(1):e10.
Correspondence / American Journal of Emergency Medicine 35 (2017) 1363-1382 1367
McDonald J, Whitelaw C, Goldsmith LJ. Radial head subluxation: comparing two methods of reduction. Acad Emerg Med 1999;6(7):715-8. - Green DA, Linares MY, Garcia Pena BM, Greenberg B, Baker RL. Randomized compar-
ison of pain perception during radial head subluxation reduction using supination-
flexion or forced pronation. Pediatr Emerg Care 2006;22(4):235-8.
Bek D, Yildiz C, Kose O, Sehirlioglu A, Basbozkurt M. Pronation versus supination ma- neuvers for the reduction of ‘pulled elbow’: a randomized clinical trial. Eur J Emerg Med 2009;16(3):135-8.
- Gunaydin YK, Katirci Y, Duymaz H, Vural K, Halhalli HC, Akcil M, et al. Comparison of success and pain levels of supination-flexion and hyperpronation maneuvers in child- hood nursemaid’s elbow cases. Am J Emerg Med 2013;31(7):1078-81.
- Garcia-Mata S, Hidalgo-Ovejero A. Efficacy of reduction maneuvers for “pulled elbow”
in children: a prospective study of 115 cases. J Pediatr Orthop 2014;34(4):432-6.
Guzel M, Salt O, Demir MT, Akdemir HU, Durukan P, Yalcin A. Comparison of hyperpronation and supination-flexion techniques in children presented to emergen- cy department with painful pronation. Niger J Clin Pract 2014;17(2):201-4.
ETView(R) video-tube versus Intubrite(R)
laryngoscope for endotracheal intubation during CPR?
Sir,
Securing the airway is one of the basic procedures performed in patients in cardiac arrest. European Resuscitation Council Guidelines strongly suggests minimizing interruptions in chest compressions [1,2]. The effectiveness of direct laryngoscopy performed by the Emergency Medical Service staff assessed in many studies is insuffi- cient [3]. Therefore, it may be helpful to use alternative methods of intubation, including the ETView VivaSight SL (ETView; ETView Ltd., Misgav, Israel), which is a endotracheal tube with integrated camera [4,5] supgraglottic airway devices [2,6,7], or different videolaryngoscopes [3,8].
The aim of this study was to evaluate the effectiveness of the first at- tempt of endotracheal intubation and the time to perform the proce- dure during the simulated adult CPR.
The study involved 35 novice physicians with no previous experience in videolaryngoscopy. All participants declared their ability to perform endotracheal intubation using a Macintosh laryngoscope.
Before the study, all the participants took part in a 10-min demon- stration. During the study we used the ETView VivaSight SL and Intubrite (Intubrite Llc, Vista, CA, USA) videolaryngoscope. In both cases, we used the endotracheal tube size 7.0 ID with the previously in- troduced stylet. Participants then took part in a 10-min practical training with the use of distinct devices in normal airway without chest compressions. For this purpose a training SimMan manikin (Laerdal, Stavanger, Norway) was used. In order to simulate the pa- tient in cardiac arrest requiring endotracheal intubation, manikin was placed on a hard, flat table for “on the bed” simulation. To stan- dardize chest compressions were performed using LUCAS 3 mechan- ical chest compression device (Physio-Control; Jolife AB, Lund, Sweden) [9]. Both the order of participants and methods of intuba- tion were random.
During the target study the chest compression system was enabled in Continuous chest compressions mode. Study participants were asked to perform endotracheal intubation using ETView and Intubrite (Fig. 1). The efficacy of the first intubation attempts, duration of the pro- cedure and the easy of the procedure according to a Visual analog scale from 0 mm (extremely easy) to 100 mm (extremely difficult) were assessed.
The effectiveness of the first endotracheal intubation attempt with the use of ETView was 100% and was higher than using Intubrite (82.8%; p = 0.023). Median time to intubate using distinct devices was varied and amounted: 25.5 [IQR; 24-28.5] s for ETView, and 34
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Fig. 1. glottic view using (A) ETView; (B) Intubrite videolaryngoscope.
[IQR; 27-37.5] s for Intubrite (p = 0.007). Study participants declared that ETView easier method for intubation (25 [IQR; 20-36]mm) com- pared with Intubrite (58 [IQR; 40-77] mm; p b 0.001).
We conclude that the ETView performed better that the Intubrite for endotracheal intubation with chest compression in adult simulations by novice physicians.
Renata Sierzantowicz, PhD, MD
Department of Surgical Nursing, Medical University Bialystok
Bialystok, Poland
Agata Dabrowska, MSc, EMT-P Marek Dabrowski, MSc, EMT-P Department of Rescue and Disaster Medicine Poznan University of Medical Sciences, Poland
Anna Drozd, MD
International Institute of Rescue Research and Education, Warsaw, Poland
Marzena Wojewodzka-Zelezniakowicz, PhD, MD
Department of Emergency Medicine and Disaster, Medical University
Bialystok, Poland Corresponding author at: Department of Emergency Medicine and Disaster, Medical University Bialystok, Szpitalna 37 Str, 15-295
Bialystok, Poland
E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2017.03.006