Central ECMO cannulation for severe dihydropyridine calcium channel blocker overdose.

Calcium channel blocker (CCB) toxicity carries a high mortality and is the sixth most fatal drug class reported to US poison centers. Amlodipine overdose is characterized by a life-threatening arterial vasodilation that compromises organ perfusion. The management of CCB intoxication is focused on maintaining adequate organ perfusion. In cases refractory to medical therapies, hemodynamic support with extracorporeal membrane oxygenation (ECMO) is warranted necessitating higher flows than usual to compensate for the vasodilation and requiring central cannulation. We present a case of a 12-year-old with severe dihydropyridine CCB ingestion, refractory to medical management and successfully treated with central ECMO cannulation. The patient was discharged home with no significant disability. Central ECMO cannulation may be helpful to facilitate adequate flows in vasodilatory shock such as CCB overdose.

Central Extracorporeal Membrane Oxygenation Support Following Calcium Channel Blocker Overdose in Children.

Refractory vasodilatory shock (RVS) following massive calcium channel blocker (CCB) overdose remains a challenging clinical entity. Peripheral venoarterial extracorporeal membrane oxygenation (ECMO) has proven useful in several cases of CCB intoxication, however, its use in the pediatric population poses unique challenges given the generally small size of pediatric peripheral vasculature in comparison to the high flow rates necessary for adequate mechanical circulatory support. As a result of these challenges, our group has adopted a "primary" central ECMO cannulation approach to the treatment of children and adolescents admitted to our center with profound RVS after CCB ingestion. We present four cases within the last year using this approach. All patients were successfully discharged from the hospital with no late morbidity at most recent follow-up. Central ECMO support in cases of massive vasodilatory shock following CCB overdose is safe and effective and should be considered early in the clinical course of these critically ill patients.

Sport Specialization's Impact on Female Adolescent Athletes' Lower-Extremity Neuromuscular Control: A Critically Appraised Topic.

CLINICAL SCENARIO: Nearly 60 million youth ages 6-18 participate in athletics within the United States. Over the last 30 years, the outlook on youth sport participation has drastically changed, resulting in an increased emphasis on performance and college sport participation. These evolving expectations have created a sense of perfectionism, demanding more time and energy to be placed into a single sport, resulting in an increased prevalence of sport specialization, and consequently, an increased rate of injury. CLINICAL QUESTION: What is the impact of sport specialization on lower-extremity neuromuscular control in female adolescent athletes? SUMMARY OF KEY FINDINGS: Four studies were included, all comparing movement efficiency and movement patterns among multisport and sport-specialized female adolescent athletes. Three studies showed that sport specialization is associated with lower-extremity biomechanical alterations that are indicative of altered levels of neuromuscular control, which can predispose an individual to an increased risk of injury. One study concluded that no differences in neuromuscular control exist when comparing sport-specialized to multisport adolescent female athletes. CLINICAL BOTTOM LINE: Sport specialization has the potential to create negative alterations in a female adolescent athletes' lower-extremity biomechanics, leading to the creation of altered levels of neuromuscular control and a possible increased risk for injury. STRENGTH OF RECOMMENDATION: Level B evidence exists to support the conclusion that sport specialization negatively affects a female adolescent athlete's lower-extremity neuromuscular control.

The Effectiveness of Hyperbaric Oxygen Therapy as a Treatment for Postconcussion Symptoms.

Clinical Scenario: Concussions are a prevalent topic in medicine. Concussion symptoms include headaches, dizziness, nausea, neuropsychiatric symptoms, and cognitive impairments, the persistence of which is referred to as postconcussion syndrome. Hyperbaric oxygen therapy (HBOT) has been proposed and evaluated as an additional treatment of these symptoms. HBOT is an innovative approach that has been considered by many but has received both criticism and acceptance. CLINICAL QUESTION: Is HBOT an effective means of reducing symptoms for individuals suffering from postconcussion syndrome (persistence of symptoms for >3 mo)? Summary of Search: The literature was searched for studies that were relevant to the clinical question. Literature provided 5 level 1 studies that were relevant enough to be considered. Clinical Bottom Line: Based on the research that is available, the authors conclude that there is more evidence to refute the use of HBOT for postconcussion syndrome than to support it. Strength of Recommendation: Four studies disprove the use of HBOT; 1 study supported the use of HBOT. These 5 studies are the same level of evidence (level 1) and provide significant findings in their studies. The strength of this recommendation is a B according to the Centre for Evidence-Based Medicine.

CLINICAL APPLICATIONS OF CRYOTHERAPY AMONG SPORTS PHYSICAL THERAPISTS.

BACKGROUND: Therapeutic modalities (TM) are used by sports physical therapists (SPT) but how they are used is unknown. PURPOSE: To identify the current clinical use patterns for cryotherapy among SPT. STUDY DESIGN: Cross-sectional survey. METHODS: All members (7283) of the Sports Physical Therapy Section of the APTA were recruited. A scenario-based survey using pre-participation management of an acute or sub-acute ankle sprain was developed. A Select Survey link was distributed via email to participants. Respondents selected a treatment approach based upon options provided. Follow-up questions were asked. The survey was available for two weeks with a follow-up email sent after one week. Question answers were the main outcome measures. RESULTS: Reliability: Cronbach's alpha=>0.9. The SPT response rate = 6.9% (503); responses came from 48 states. Survey results indicated great variability in respondents' approaches to the treatment of an acute and sub-acute ankle sprain. CONCLUSIONS AND CLINICAL RELEVANCE: SPT applied cryotherapy with great variability and not always in accordance to the limited research on the TM. Continuing education, application of current research, and additional outcomes based research needs to remain a focus for clinicians. LEVEL OF EVIDENCE: 3.

Skinfold thickness at 8 common cryotherapy sites in various athletic populations.

CONTEXT: Researchers have observed slower cooling rates in thigh muscle with greater overlying adipose tissue, suggesting that cryotherapy duration should be based on the adipose thickness of the treatment site. Skinfold data do not exist for other common cryotherapy sites, and no one has reported how those skinfolds might vary because of physical activity level or sex. OBJECTIVE: To determine the variability in skinfold thickness among common cryotherapy sites relative to sex and activity level (National Collegiate Athletic Association Division I athletes, recreationally active college athletes). DESIGN: Descriptive laboratory study. SETTING: Field. PATIENTS OR OTHER PARTICIPANTS: Three hundred eighty-nine college students participated; 196 Division I athletes (157 men, 39 women) were recruited during preseason physicals, and 193 recreationally active college athletes (108 men, 85 women) were recruited from physical education classes. INTERVENTION(S): Three skinfold measurements to within 1 mm were taken at 8 sites (inferior angle of the scapula, middle deltoid, ulnar groove, midforearm, midthigh, medial collateral ligament, midcalf, and anterior talofibular ligament [ATF]) using Lange skinfold calipers. MAIN OUTCOME MEASURE(S): Skinfold thickness in millimeters. RESULTS: We noted interactions among sex, activity level, and skinfold site. Male athletes had smaller skinfold measurements than female athletes at all sites except the ATF, scapula, and ulnar groove (F7,2702 = 69.85, P < .001). Skinfold measurements were greater for recreationally active athletes than their Division I counterparts at all sites except the ATF, deltoid, and ulnar groove (F7,2702 = 30.79, P < .001). Thigh skinfold measurements of recreationally active female athletes were the largest, and their ATF skinfolds were the smallest. CONCLUSIONS: Skinfold thickness at common cryotherapy treatment sites varied based on level of physical activity and sex. Therefore, clinicians should measure skinfold thickness to determine an appropriate cryotherapy duration.

Are room temperature and thermal neutral synonymous terms? An investigation of common therapeutic modality control variables.

CONTEXT: Therapeutic modality control variables are thought to be thermal neutral, a term sometimes used interchangeably with room temperature. We question this common assumption. OBJECTIVE: To determine thermal neutrality of common therapeutic modality control variables. DESIGN: We performed 5 laboratory experiments, including (1) water temperature over 3 weeks in 3 different containers (glass, plastic, and polystyrene); (2) water temperature and volume of 4 beakers (2 insulated, 2 uninsulated) over 4 weeks, with 1 beaker of each type covered by polyethylene; and skin interface temperature of (3) a dry, nonheated hydrocollator pack held against the chest, (4) kitty litter applied to the knee, and (5) room-temperature ultrasound gel to the forearm. SETTING: Therapeutic modalities laboratory. PATIENTS OR OTHER PARTICIPANTS: College student volunteers were subjects in experiments 3, 4, and 5. MAIN OUTCOME MEASURE(S): We measured temperature and volume change. Data were evaluated using descriptive and interferential statistics. RESULTS: Water temperature plateaued significantly below room temperature. Temperatures significantly increased in all but the open, insulated container. Open containers plateaued at approximately 2 degrees C below room temperature and lost significant amounts of water; closed containers plateaued at room temperature with negligible water loss. In experiments 3 through 5, skin temperatures rose significantly during hydrocollator pack, kitty litter, and ultrasound gel application. CONCLUSIONS: Room-temperature water baths, dry hydrocollator packs, kitty litter, and ultrasound gel were not thermally neutral. Room temperature should not be used synonymously with thermal neutral. Care must be taken to ensure that control variables truly are controlled.

The uncertainty (validity and reliability) of three electrothermometers in therapeutic modality research.

CONTEXT: Data from electrothermometers are used to determine therapeutic modality usage, but the value of experimental results is only as good as the data collected. OBJECTIVE: To determine the reliability and validity of 3 electrothermometers from 2 manufacturers. DESIGN: A 3 x 4 x 17 factorial with repeated measures on 2 factors. Independent variables were trial (1, 2, 3), thermometer (mercury thermometer, Iso-Thermex calibrated from -50 degrees C to 50 degrees C, Iso-Thermex calibrated from -20 degrees C to 80 degrees C, and Datalogger), and time (17). SETTING: Human Performance Research Center. INTERVENTION(S): Eighteen thermocouples were inserted through the wall of a foamed polystyrene cooler, and 6 were connected to each of the 3 electrothermometers. The cooler was positioned on a stir plate and filled with room-temperature water (18.4 degrees C). A mercury thermometer was immersed into the water bath. Measurements of the water bath were taken every 10 seconds for three 3-minute trials. MAIN OUTCOME MEASURE(S): The temperature variability of 3 electrothermometers was taken from a calibrated mercury thermometer. RESULTS: The Iso-Thermex electrothermometers did not differ statistically from each other in uncertainty (validity error +/- reliability error = 0.06 degrees C +/- 0.03 degrees C +/- 0.03 degrees C +/- 0.02 degrees C, P < .05), but both differed from the Datalogger (0.64 degrees C +/- 0.20 degrees C, P < .05). The Datalogger temperature was consistently higher than the mercury thermometer temperature. CONCLUSIONS: The Iso-Thermex electrothermometers were more stable than the Datalogger, and values were within the published uncertainty (+/-0.1 degrees C) when used with PT-6 thermocouples. The Datalogger we used had an uncertainty of measurement greater than that indicated in the user's manual (approximately +/-0.52 degrees C). Uncertainty of +/-0.84 degrees C can significantly influence the interpretation of results when intramuscular temperature changes are usually less than 5 degrees C.