"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