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  • EMplify, the new evidence-based podcast, is now available on iTunes and Google Play!
  • Pediatric Emergency Medicine Practice Points and Pearls
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EMplify, the new evidence-based podcast, is now available on iTunes and Google Play! EB Medicine's ED CLEAR
 

Current Issues

Emergency Medicine Practice

Sedative-Hypnotic Drug Withdrawal Syndrome: Recognition And Treatment

Abstract:
Emergency Medicine PracticeSedative-hypnotic drugs include gamma-Aminobutyric acid (GABA)ergic agents such as benzodiazepines, barbiturates, gamma-Hydroxybutyric acid [GHB], gamma-Butyrolactone [GBL], baclofen, and ethanol. Chronic use of these substances can cause tolerance, and abrupt cessation or a reduction in the quantity of the drug can precipitate a life-threatening withdrawal syndrome. Benzodiazepines, phenobarbital, propofol, and other GABA agonists or analogues can effectively control symptoms of withdrawal from GABAergic agents. Managing withdrawal symptoms requires a patient-specific approach that takes into account the physiological pathways of the particular drugs used, as well as the patient's age and comorbidities. Adjunctive therapies include alpha-2 agonists, beta blockers, anticonvulsants, and antipsychotics. Newer pharmacological therapies offer promise in managing withdrawal symptoms.

Points

  • Sedative-hypnotic agents are the second most frequent drug class to cause an emergency de­partment (ED) visit. This category includes benzodiazepines, barbiturates, baclofen, GHB (gamma-hydroxybutyric acid) and GBL (gamma-butyrolactone).
  • Cessation of sedative-hypnotic agents leads to decreased GABA-mediated inhibitory tone and increased NMDA-mediated excitatory tone. This results in autonomic stimulation (tachycardia, hy­pertension, hyperthermia, diaphoresis), tremors, hallucinations, and seizures.

Pearl

  • Diazepam and chlordiazepoxide are the preferred agents to treat sedative-hypnotic withdrawal because they are long-acting, with active metabolites.

Pediatric Emergency Medicine Practice

Pneumothorax In Pediatric Patients: Management Strategies To Improve Patient Outcomes

Abstract:
Pediatric Emergency Medicine PracticeThe clinical presentation of pneumothorax is highly variable. Spontaneous pneumothoraces may present with subtle symptoms when a small air leak is present, but can progress to hemodynamic instability in the setting of tension physiology. The etiologies are broad and the severity can vary greatly. A trauma patient with a pneumothorax may also have the added complexity of other potentially life-threatening injuries. While there is a wealth of evidence-based guidelines for the management of pneumothoraces in the adult literature, the approach to pediatric patients is largely extrapolated from that literature without a significant evidence base. In this issue, aspects of the history and physical examination, the use of various diagnostic imaging modalities, and the range of interventions available to the emergency clinician are discussed.

Points

  • Underlying conditions and diseases that increase the risk of secondary pneumothorax include pulmonary, infectious, systemic, and iatrogenic etiologies. Recent procedures involving the neck, chest, or abdomen can lead to an iatrogenic pneumothorax.
  • For a traumatic pneumothorax, evaluate for concomitant injuries including rib fractures, pulmonary contusions, subcutaneous emphysema, and cardiac injuries.
  • Chest radiography is considered gold-standard imaging for clinically significant pneumothoraces. The pleural line will be seen with the absence of vascular markings beyond this demarcation.

Pearl

  • Place a chest tube before or immediately after intubation, as intubation can convert a patient to a positive-pressure physiology, leading to worsening pneumothorax.

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EMplify, the new Emergency Medicine Practice podcast, is now available

 

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Last Modified: 03/27/2017
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