More Abstracts

• Steg, P.G., et al, Chest 128(1):21, July 2005: Another study sponsored by Biosite (the company that makes BNP) from the BNP (Breathing Not Properly) data base- they state that BNP is better than echo in determing CHF (BNP averaged 683 in CHF vs. 129 in non-CHF). The bottom line is there was a lot of data mining in this study that heavily favored stats towards a pro-BNP stance. I've spoken with a cardiologist from the Cleveland Clinic who feels that BNP is a pretty worthless test in this setting. I really don't bother ordering it anymore as I feel that my clinical judgment (history, physical exam and CXR) provides more information than this one lab test. The only people who I find are still interested in its results are some hospitalists.
• Goodacre, S., et al, Ann Intern Med 143(2):129, July 19, 2005: Clinical judgment is as good as the Wells' criteria for diagnosing DVT. The two most important questions are whether they had a prior DVT or current malignancy. Nothing horribly new here.
• Oudega, R., et al, Ann Intern Med 143(2):100, July 19, 2005: D-dimer is only beneficial for its negative predictive value in low-risk patients for DVT.
• Squire, B.T., et al, Acad Emerg Med 12(7):601, July 2005: Use of bed-side U/S (after a 30 minute training session) to diagnose a superficial abscess is significantly improved. This would be very helpful to determine whether there is some pus there before doing an I&D. This would be a nice adjunctive use of a SonoSite (ahem twice Evan)...
• Murray, J.J., et al, Otolaryngol Head Neck Surg 133(2):194, August 2005: Interesting study of confirmed sinusitis (with imaging and bacteriological aspirate) randomized to either Azithromycin 2 g microsphere as a one time dose vs. 10 days of levaquin. Same efficacy between the treatment. A couple of caveats: a) drug-sponsored study and b) they didn't compare to placebo (some patients may have gotten better without treatment). My bottom line is that if I'm going to treat sinusitis (which typically is a 14 day course) it may be beneficial to do the 2 gram Azithromycin dose in the ED and no further antibiotics required. They had a slightly higher adverse effects (23% vs 15%) but not serious (GI issues).
• Salerno, S.M., et al, Arch Intern Med 165:1686, August 8/22, 2005: Oral pseudophedrine does NOT cause a clinical increase in SBP or DBP.
• Prescott, L., Ann Emerg Med 45(4):409, April 2005: Use of IV N-acetylcysteine is equivocal in efficacy with oral therapy in treatment of acute acetaminophen toxicity. Bottom line is to give oral N-AC if they tolerate PO, but it's ok to use IV in serious overdose or unable to tolerate PO. The maximum effects are found in the first eight hours.
• McEvoy, S.P., et al, Br Med J 331:428, August 2005: Not so much that it'll change your practice, but the use of a cell-phone (even hands-free system) is associated with a four-fold increase in MVC's.

Dessert

here are some more tidbits (this time with citations). I'll be going back and adding citations to the prior studies....

• Schwartz, D., Israeli Med Assoc J 7:502, August 2005: routine use of PT/PTT is not required in the general evaluation of ACS. The results don't typically alter the outcome or management. The only time it'd matter is if you're going to start someone on heparin and that still was only seen in one patient affecting management. It'd save $, however I don't realistically see us changing our CP protocol unless there's a good consensus about it
• Sabatine, M.S., et al, JAMA 294(10):1224, September 14, 2005 : If somebody is going to get PCI due to STEMI, it's better to load these patients with Plavix 300 mg PO then 75 mg PO q day.
• On an aside note while it's in my brain, remember to type q day or q 24 hours vs qd (this is from pharmacy). Also avoid MSO4, MS, etc (use morphine)
• Novo-7 will be approved by P&T and will be soon available from the pharmacy. Become familiar with this for treatment in intracerebral bleeds
• Fonarow, G.C., et al, Am J Card 96(5):611, September 1, 2005: Some suggestions that there's a benefit to early statins administration in AMI with a decrease in significant bad outcomes. There needs to be a randomized control trial to support these claims. Expect to hear more about this from the cardiologists as it was a focus of their meetings in New Orleans this year.
• Morrison, L.J., et al, Resuscitation 66:149, August 2005: Biphasic defibrillation was better than monophasic defibrillation in converting to an organized waveform, but no change in spontaneous circulation, survival, etc. It may help you get a prettier rhythm but no change in survival.
• Milling, T.J., et al, Crit Care Med 33(8):1764, August 2005: A significant decrease in cannulating central lines with U/S guidance. This has been seen in several other studies. Bottom line is once we get a portable U/S machine-SonoSite (ahem Evan) we'll be able to significantly improve our TLC placement. I would highly recommend that one of our first inservices with these machines would be on central line placement. Something to keep in mind as well for aggressive early goal-directed therapy for sepsis and perhaps replacing dislodged HD catheters.
• Anderson, B.A., et al, Am J Surg 190(3):474, September 2005: PLEASE NOTE AND FORWARD TO RADIOLOGY- to rule out appendicitis, a CT Abd/pelvis does NOT require PO contrast. The only problem is they used rectal contrast (I think I'd take the oral). But still this would significantly decrease our time to CT scan for appy evaluation.
• Rady, M.Y., et al, Arch Surg 140:661, July 2005: No difference in ICU patients on vasopressors when treated with corticosteroids, even if they had a high or low cortisol and/or responding to or not to ACTH.
• Abraham, E., et al, New Engl J Med 353(13):1332, September 29, 2005: Xigris (very expensive drug) didn't improve outcome/mortality for patients with severe sepsis and caused significant bleeding. May actually do more harm, costs a lot and hasn't proven benefit. Bottom line- I won't be asking the intensivists if we should start Xigris.
• Signs/symptoms of botulism are a floppy baby with constipation, ptosis, poor sucking, poor feeding and bulbar weakness. Classically starts with weakness from cephalad to caudad.
• Parlak, I., et al, Emerg Med J 22:621, September 2005: IV metoclopramide given as a slow infusion for treatment of cephalgia with or without nausea/vomiting produced the same results with significantly decreased rates of akathisia when given as a bolus (25% vs 5%). Bottom line- consider it in headache patients but give it as a slow infusion to decrease side effects.
• Still no studies demonstrating a significant clinical difference between levalbuterol (Xopenex) and albuterol.
• DiRusso, S.M., et al, J Trauma 59:84, July 2005: Takes a strong stance that field prehospital pediatric intubation does not show ANY benfit and in fact may produce a negative outcome. It's better to scoop, bag and run.
• That's it for this session. Hope these helped...

Late-Night Snack

The 3rd and latest edition of the PEMS blog. Hope you guys are getting something out of this. I'm going to be culling two more months of abstracts and will then move on to some interesting case presentations. If you have any interesting cases out there, interesting EKG, radiographs or anything else, let me know.

You'll also note the debut of the PEMS logo to the website. I'm still working on getting it to be permanently at the top of the page. Baby steps for the neophyte...

• Green, R., et al, Pediatrics 116(4):978, October 2005: Yet another study demonstrating that IV analgesia (morphine) does NOT mask or affect the examination of a pediatric acute abdomen. Not so important at our facilities (always was more of an issue in residency), but still it makes the diagnosis easier because you're able to get a better exam and accurately diagnose a surgical abdomen.
• Sanchis, J., et al, J Am Coll Card 36(3):443, August 2, 2005: They looked at patients with CP, a normal EKG and serial negative Troponin's at 6, 8 and 12 hours. Low-risk eh? 5% ended up having a significant bad outcome within 2 weeks (higher risk if older than 67, diabetic, increasing CP, etc). Bottom line is that while we may effectively rule out someone, there's a decent chance that given risk factors they still have an underlying CAD condition.
• Shah, M.R., et al, JAMA 294(13):1664, October 5, 2005: This demonstrated no benefit from Swann-Ganz catheters in trauma patients. Doesn't really affect us, but is pertinent from debates during residency with the surgeons.
• Tseng, M.Y., et al, Stroke 36:1627, August 2005: Statins used in subarachnoid hemorrhage in order to decrease the incidence of vasospasm (what you want to prevent - why we use Nifedipine); showed some benefit in endpoint outcomes, but some questionable stats. Bottom line is expect to see a greater push of statins used in both SAH's and MI's. Whether that directly affects us in the ED or they just have to be started in 24 hours remains to be seen.
• Ghosh, A., Emerg Med J 22:732, October 2005: Steroids in people with idiopathic sensorineural hearing loss. A lack of power doesn't help support the use but there may be a small benefit.
• Smith, J.E., Br J Sports Med 39:503, August 2005: Exertional heat stroke (small problem in Phoenix) - evaporative is the best mechanism. I personally have a tech spray them with a water bottle and fans. Ice packs in the axilla, groin, etc take too long and aren't as efficacious. Obviously immersion in ice baths is not appropriate because they either have AMS or are too alert to be comfortable in that position.
• Keyzer, C., et al, Radiology 236:527, August 2005: Comparison of U/S vs. CT WITHOUT contrast (novel concept) to determine appendicitis- CT is much better than U/S. The only time I have felt U/S is appropriate is in thin children when you want a quick possible answer, do not want to subject the child to a CT and you don't feel it's a slam-dunk appy (where no imaging studies are required).
• Ward, J.I., et al, N Engl J Med 353(15):1555, October 13, 2005: Acellular pertussis vaccine works. There is pertussis seen on the reservation sometimes in Northern Arizona. Also note that pretty soon our Td will also include the pertussis vaccine THAT WE GIVE IN THE ED so become familiar with inclusion/exclusion criteria.
• Stein, J., et al, Ann Emerg Med 46(5):412, November 2005: Clinical judgment is as accurate as flu swabs in diagnosing influenza. So of course why order the test if it's not going to change your management?
• Knopp, J.A., et al, Osteoporosis Int 16:1281, October 2005: Calcitonin for treating acute pain of osteoporotic vertebral fractures; it doesn't work immediately but within one week patients have dramatic decrease in pain, need for analgesia and ability to perform ADL's. For all the vertebral compression fratures we see in the elderly, this is interesting to note. I'll try to find the exact treatment regimen, but I think this will move to being the standard of care.
• Amirfeyz, R., et al, J Hand Surg 30B(4):361, August 2005: The hand elevation test: Elevating the hands for one minute- supposedly a better test in diagnosing Carpal tunnel syndrome. Tinnel's usually is not as valuable and Phalen's a little better. The problem is they used Phalen's as the gold standard. Just more "test name" dropping for the ED
• Hauck, F.R., et al, Pediatrics 116(5):e716, November 2005: Pacifiers decrease the incidence of SIDS. Start them after one month and end at one year. Number needed to treat is 1 in 2100. Starting them before one month encourages breat feeding (especially if Barrali's man pecs are nearby). Interesting tidbit though.
• Bijur, P.E., et al, Ann Emerg Med 46(4):362, October 2005: Morphine at a dose of 0.1 mg/kg (even in adult) doesn't provide significant pain decrease without requiring opioid antagonists. The bottom line is we're probably undertreating pain at some times, but this needs to be balanced with clinical judgment.
• Brown, G., Emerg Med J 22:720, October 2005: there are no sensitive or specific EKG findings in PE. Even sinus tachycardia was found in less than 50% of patients.
• Remember you treat accidental epinephrine injection in the fingers with phentolamine.

Tasty May Nuggets #2

• Nagurney, J.T., et al, J Emerg Med 29(4):409, November 2005: CK-Mb more sensitive than Trop I in CP of duration less than 6 hours. If you look at CK-Mb and Trop I at hours 0 and 2, CK-MB has sensitivity of 82% compared to 62% of Trop I. In CP of duration greater than 6 hours, it still is more sensitive. While Trop I is more SPECIFIC, CK-MB is proving to be much more sensitive in determining NSTEMI. Thus you need to check markers at least 6 hours after presentation and realize that IF your Trop's are normal w/ an elevated CK-Mb, you can't blow it off.
• van 't Hof, A.W.J., Eur Heart J 7(Suppl K):K36, October 2005: PCI compared to thrombolytics in long-standing CP shows no diffference in outcome. The key bottom line fact is this: IF you can get door to cath time in less than 90 minutes, the pt is marginally better off w/ PCI. IF you can't get them in that time frame OR the duration of symptoms has been greater than a couple of hours, the difference b/w PCI and thrombolytics is pretty negligble. On an aside note, a refresher on revascularization arrhythmias - remember they can happen and you do nothing about them. I'll see if I can dredge more info up on this.
• Ray, K.K., et al, J Am Coll Card 46(8):1405, October 18, 2005: High-dose lipitor vs standard dose pravachol in ACS - thus high-dose statins vs. normal dose statins. Not really affecting you in the ED, but you might get it for admit orders or asked by pts. Some data mining from this study and they state that high-dose early statins may be of some benefit. Not a good study and really doesn't bore out anything that should change your practice.
• The COMMIT (Clopidogrel and Metoprolol in Myocardial Infarction Trial) Collaborative Group Lancet 366:1607, November 5, 2005: Adding plavix to ASA in STEMI, excluding all w/ PCI and only 1/2 got a thrombolytic. Study treated all w/ ASA +/- Plavix 75mg qd x 4 wks; 10.1% vs 9.2% decrease in significant bad outcomes. Again, nothing that will change your ED care and not a strong study, but something to know about when it comes to talking w/ cardiologists, hospitalists, etc. Done in China and probably not really showing any significant difference in outcome when you extrapolate the data to the U.S.
• We break up this cards feast w/ two tasty bite-sized morsels courtesy of P-Mac...
• Bakody's sign: Aka "shoulder abduction test"- conducted w/ the pt lying or sitting. The arm is actively or passively elevated through abduction so that the hand or forearm rests on top of the head. A decrease in or relief of symptoms indicates a cervical extradural compression problem (i.e. herniated disc or nerve root compression usually in C5-6 area.
• Jolly's sign: If a pt holds their hand on the top of their head to relieve the pain
• W/ C5-6 compression watch the pt sit up from a chair, if they have 3/5 triceps weakness they'll deviate to that side to the lack of strength when pushing off the arm rests.
• Now back to our regularly scheduled blogging...
• The COMMIT (Clopidogrel and Metoprolol in Myocardial Infarction Trial) Collaborative Group Lancet 366:1622, November 5, 2005: IV B-blockers followed by oral B-blockers can cause some hemodynamic instability in STEMI (I know you're shocked), but they do help after two days w/ regards to arrhythmias. Not a lot of strong evidence showing the benefit of B-blockers early on (more benefits later on in course when we're not around). Consider the B-blockers more in a sympathetic overdrive (tachy, HTN w/ CP).
• Singer, A.J., et al, Acad Emerg Med 12(10):965, October 2005: Low-risk ACS pts (Negative EKG, negative labs, no clinical findings, no active CP) can be transferred to medical floor OFF MONITORS without a change in outcome. Thus feel free to send the pt OFF monitors with a clean conscience.
• Wang, C.S., et al, JAMA 294(15):1944, October 19, 2005: Your clinical judgment and using PE, CXR, etc is a better indicator of CHF vs using BNP. BNP is proving to be a pretty useless test in the ED.
• Sen, A., Emerg Med J 22:887, December 2005: Still no evidence demonstrating a positive benefit to pre-hospital ETT and it also results in an increased field time.
• Holtkamp, M., et al, Arch Neurol 62:1428, September 2005: In a patient with status epilepticus without a history of sz disorder who's refractory to typical trx (benzos and dilantin) consider encephalitis (i.e. West nile virus, etc)
• Yamamoto, L.G., et al, Clin Ped 44 :693, October 2005: Crying doesn't cause pediatric TM's to be red
• Leontiadis, G.I., et al, Aliment Pharmacol Ther 22(3):169, August 2005: In bleeding ulcers/UGIB, there's not much benefit from PPI's and really no demonstrative benefit from H2 blockers. This is consistent with other studies.
• McGillivray, D., et al, J Ped 147:451, October 2005: Bag U/A vs cath U/A in infants. Bottom line is that bag U/A is about 82% sensitive, but 30% less specific. A reasonable approach is to get a bag U/A in a pt without a history of UTI/pyelo. If the bag U/A is negative, you're done. If it's positive, consider a cath U/A and cx. Never bother getting a culture from a bag U/A.
• Badiaga, S., et al, J Emerg Med 29(4):375, November 2005: In a patient who's been travelling to Africa, with fever, jaundice and joint pain- consider malaria.
• Thompson, S.K., et al, Arch Otolaryngol Head Neck Surg 131:900, October 2005: Use of steroids in mononucleosis- only indication is in airway compromise or impending airway issues. They don't change admission rate, LOS, or outcome. From the more important "Journal of Anectdotal Mattison Evidence" steroids made me feel so much better when I had mono. And of course anectdotal evidence always trumps hard facts...
• Kennedy, M., et al, Ann Emerg Med 46(5):393, November 2005: Blood cx in pneumonia patients who were admitted; 50% of + blood cx were pneumoccocus; 25% staph (who usually didn't do well w/ Abx); 5-7% of admitted patients had positive blood cx. It would take 125 patients with blood cx to have Abx choice changed to make them matter. You'll still probably get the blood cx, but it doesn't usually ever affect management.
• Butler, J., Emerg Med J 22:815, November 2005: Crichoid pressure (Sellick's maneuver) has never been confirmed to provide clinical benefit to prevent aspiration. This technique actually was derived from Dr. Sellick who found that three patients had regurgitation of gastric juices after release of crichoid pressure. The BURP technique is probably your best bet.
• Anderson, D.R., et al, J Emerg Med 29(4):399, November 2005: If you're going to r/o PE in a pt, you need to do BOTH duplex U/S and CT Chest. One study has shown up to 18% of pt's w/ negative CT chest had a positive duplex LE U/S and later found to have PE.
• That's it for now.... Hopefully that will keep you sated for a moment.

"Spoon Feeding" May 2006

Note: This is the initial "spoon feeding" session. I can provide these on a roughly monthly basis if people think they are of benefit. I'll also be including interesting patient case reports, five-minute lectures and anything else you guys think might be of educational value.

The key to these spoon-feeding sessions is to keep the information simple, concise and bulleted (i.e. bite-sized nuggets of info). If you like this format, have comments or complaints, let me know. Feel free to "blog" your comments, any useful information you have found or other useful tidbits. Consider this a community forum so your input only improves the general knowledge base. Also note that since this is a community forum, pay particular attention to the information you divulge and any patient identifying characteristics. And now on to some tasty appetizers...

• Hong, S.N., et al, Circ J 69:1472, December 2005: End-terminal pro-BNP (our new lab test at CRH if I'm not mistaken?) checking correlation between elevated BNP and angiograms in South Korea - relation b/w magnitude of coronary artery occlusion and the magnitude of elevated BNP. There was a relationship between the magnitude of BNP and coronary artery lesions. Nothing in the study will affect your management as the pointy-head statistics didn't show a clinical significance.
• Chen, E.H., et al, Ann Emerg Med 46(5):440, November 2005: Telemetry observation admissions (vs. medical) rarely are useful in low-risk ACS pts w/ regards to preventing bad outcomes just because they are on the tele floor. Low-risk patients have a normal EKG, normal markers, and no active CP. Some support for admitting low-risk ACS pts to medical floor. We're already moving towards that path. Free up those tele beds.
• Buckmaster, N.D., et al, Intern Med J 36(1):12, January 2006: High-risk ACS pts do better w/ heparin. Low-risk and intermediate risk pts do NOT have additional benefit of receiving heparin. Thus heparin only for the high-risk ACS pts
• Remember your high-risk ACS pts are defined by any of the following: a) ST elevation b) > 20 minutes of CP w/ ST depression OR T-wave inversion in 2 or more contiguous leads that changes w/ CP c) baseline elevated trop I d) life-threatening arrythmias e) LV failure f) MI or revascularization w/in 3 months.
• Mahaffey, K.W., et al, JAMA 294(20):2594, November 23/30, 2005: Lovenox vs heparin in HIGH-RISK ACS pts - no difference in any major stats b/w the two. These two are equivalent. Heparin is cheaper, lovenox is easier and more convenient. But b/w the two no difference in major outcomes.
• Ogata, T., et al, J Vasc Surg 42:891, November 2005: 8-fold higher incidence b/w siblings w/ AAA's - 29% of brothers and 11% of sisters who had a AAA- their sib had one. Consider asking about family hx if you're worried about a new AAA in a pt. This is more of a primary care study, but interesting to note.
• Giglio, P., et al, Emerg Radiol 12(1-2):44, December 2005: CT head in routine syncope is not required and doesn't add anything to the work-up. Very interesting if you think how often we order a head CT in syncope. If it's a true transient event with normal mental status, and no focal neuro deficits a head CT is not required or beneficial. This would change my management, how about yours?
• Sorimachi, T., et al, Neurosurgery 57(5):837, November 2005: Intracerebral hemorrhages (non-aneurysmal) - anti-fibrinolytics are beneficial with strict BP control with nifedipine (SBP <140).>
• Merenstein, D., et al, Pediatrics 116(6):1267, December 2005: If you discuss with parents about the use of antibiotics in peds OM and share the decision-making process with the parents, there's a significant decrease in antibiotic use and increase in parent satisfaction.
• Izri, A., et al, Clin Infect Dis 42:e9, January 15, 2006: Washing lice (fomites) with detergent at higher than 50 degrees celsius is required to sufficiently kill them. The key is very high temperatures to kill all the lice.
• Pilsczek, F.H., et al, Heart & Lung 34:402, November-December 2005: Consider ordering only PT/INR on coumadin patients, PTT on heparin patients and neither on lovenox patients. Straightforward stuff, but doubt it'll change your ED practice. More of an inpatient consideration.
• Remember PTT only evaluates your intrinsic coagulation pathway. This will only be abnormal in hemophilia, vonWillebrand's disease or heparin OD.
• Schroeder, A.R., et al, Arch Ped Adol Med 159:915, October 2005: Consider bag urine specimens over cath in infants. If it's negative, you have your answer. If it's positive and you're worried about false positive, then consider a cath U/A. Of course you have to wait for the specimen in the bag and you may still end up cathing them. Of course if it's negative bag U/A you've saved an infant/parents a cath.
• Han, Y.Y., et al, Pediatrics 116(6):1506, December 2005: Mortality more than doubled in a peds hospital using computer order-entering system. Demonstrates that current systems are tedious, have inherent errors and sometimes inefficient.
• Hippisley-Cox, J., et al, Br Med J 331:1310, December 2005: Increased risk of UGIB w/ COX-2 inhibitors and NSAIDs. No news here.
• Babl, F.E., et al, Ped Emerg Care 21(11):736, November 2005: Pediatric pts that are NPO for procedural sedation with nitrous oxide (something we don't have/use) didn't have a change in adverse effects over a non-fasting child. More support for a less strict regimen of PO status in pediatric patients undergoing procedural sedation.
• Judge, B.S., et al, Ann Emerg Med 46(5):462, November 2005: There is no conclusive evidence to dive patients with carbon monoxide poisoning. If you have no other option, consider it. There just hasn't been any good studies demonstrating added benefit over high-flow O2. Maybe considerations are a little different because we have it readily available and transportation risks are a minimum. Don't be mad at me Brian.
• Kabrhel, C., et al, Acad Emerg Med 12(10):915, October 2005: The Well's criteria in determining the probability of PE hasn't demonstrated significant clinical correlation. Your best pre-test criteria of determining PE is your clinicial judgment and maintaining a high-index of suspicion. Any comments Evan?

That's is for now. Remember, if you find this helpful, let me know.

Erik