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.