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.