June Nubbins

• I'm looking to get people together in August some time that we can get together and have a group "review" session for the LLSA test for EMCC. Look for dates and times coming up. Before you take the test this year, you may want to wait for the group.
• I'm going to be posting the first patient case blog in the next couple of days (once I get the home office and scanner up and running). Should be an interesting one so keep an eye out for it. Now on to our journal reviews...
• Allen, T.L., et al, Am J Emerg Med 23:253, May 2005: PO contrast is not required in CT Abd/pelvis for blunt trauma, especially looking at diaphragmatic injuries. This study is limited by numbers (as you'd expect with a rare injury).
• Sokolove, P.E., et al, Acad Emerg Med 12(9):808, September 2005: Big surprise, but a seatblet sign in pediatric patients should clue you into the possibility of abdominal trauma and get a CT.
• Topol, E.J., N Engl J Med 353(2):113, July 14, 2005: Editorial from the former cardiology chair at the Cleveland Clinic- bottom line is that nesiritide is NOT a good drug to use in the ED for CHF exacerbation (same results as NTG gtts with a much higher cost and increase in side effects and mortality).
• Masip, J., et al, JAMA 294(24):3124, December 28, 2005: Non-invasive ventilation (BiPAP/CPAP) decreases mortality in acute pulmonary edema and should be front-line therapy. These are small, pool studies, but the bottom line is I'm a big proponent of NIV in the treatment of acute CHF exacerbation with respiratory symptoms and pulmonary edema. It has kept me from intubating quite a few patients and given in conjunction with lasix, NTG gtts, and Morphine usually will turn around extremely ill patients within 30-45 minutes. Again, from the "Journal of Mattison Anectdotal Evidence"...
• Chen, W.L., et al, Emerg Med J 23:e01, January 2006: A case report (so take it with a grain of salt) of a patient with vertebral artery dissection AFTER chiropractic manipulation. Some info to provide your patients who are interested in this option.
• Taddio, A., et al, Can Med Assoc J 172(13):1691, June 2005: Topical liposomal lidocaine provides equal anesthetic relief in 30 minutes when compared to subQ lidocaine. It takes about 30 minutes to be effective (quicker than EMLA) and would be a nice choice in peds.
• Kim, T.Y., et al, Ped Emerg Care 22(1):28, January 2006: Lethargy and swelling around the shunt size are the only statistically significant signs of ventricular shunt malfunction (that correlate with CT). Also look for headaches, N/V and seizures. Obviously you'll do a CT (to look for enlarged ventricles). The other films you can order our shunt series (plain film x-rays). I personally have never seen a shunt series that was beneficial. General opinion also agrees with the fact that this does not offer much in the way of work-up (the CT is the key).
• Benson, P.C., et al, Ann Emerg Med 47(1):100, January 2006: Emirical IV acyclovir is indicated in suspected cases of viral ENCEPHALITIS. In the cases of viral meningitis, it's not warranted, but if you suspect encephalitis (AMS), go ahead and give it.
• Iosif, A., et al, Can Med Assoc J 173(12):1498, December 6, 2005: Not an important study, but it's interesting to note that there appears to be no correlation between lunar cycles and increasing mania or "madness". Thus there is no true "full moon effect".
• Lang, E., et al, Can Med Assoc J 174(3):313, January 2006: An interesting study from Montreal where family practice doctors received an emailed transcript of the ED visit, labs, etc. the day AFTER the ED visit. Sounds like a great idea that would improve communication, follow-up, etc. Actually there was an INCREASE in multiple consultations and other factors that you'd assume were improved with this information. It sure sounds like a nice idea though and it'd be interesting if the primary doctors could receive an email of the WEBMEDX typed charts of their patients after the ED visits. Something to consider if feasible.
• One CT of the Abd/pelvis is equivalent to 500 CXR's in the pediatric population. A fun fact for parents who are adament about a CT when you don't think it's warranted.
• Ozucelik, D.N., et al, Int J Clin Pract 59(12):1422, December 2005: A Turkish study (have to plug that) that utilized Reglan 10 mg IV 15 minutes before NGT placement showed a significant decrease in discomfort and nausea. Consider it the next time you have a patient who's not tolerating or doesn't think they'll tolerate an NGT well.
• Jefferson, T., et al, Lancet 367:303, January 28, 2006: Antivirals (neuraminidase inhibitors) for influenza are only efficacious in the acute illness, when treated early and may shorten the course by only 24 hours.
• Shafi, S., et al, J Trauma 59:1140, November 2005: An interesting study that supports my experience that intubation with positive pressure ventilation (PPV) in hypotensive trauma patients caused an increase in hypotension and overall lower survival. Obviously there's a selection bias in that the sicker patients needed to be intubated. The take home point is be careful with PPV in hypotensive patients (even if they aren't trauma patients, i.e. COPD).
• Christopher Study Investigators JAMA 295(2):172, January 11, 2006: This is a new algorithm looking at PE: a little bit more simple in that you're either a) low-risk or b) non-low risk. You perform a D-dimer in low-risk only and don't treat them if negative. You do a CT angiogram in all the others and treat if positive. There were some technical problems with the study and follow-up stats, but you may be hearing more about this.
• Evans, R., Emerg Med J 23:64, January 2006: Very interesting study that examined the use of absorbable sutures in the pediatric population. There was no difference in cosmesis or complications, PLUS there was an actual decrease in dehiscence. The bottom line is that absorbable sutures will do just as well and parents don't have to bring back the child for suture removal. The only question I would have is with regards to facial wounds where you want the sutures out at an exact time frame (5 days) in order to diminish scarring. Other than that any other sutures should be absorbable in pediatrics.
• One last reminder for all docs and PA's- when writing for cipro or levaquin (any fluorquinolone) remember that the PO form has 100% bioavailability. Thus if the patient can swallow a pill, give it to them PO. It's much cheaper than IV and works just as well. Also consider how much easier and quicker it is to administer.
• That's it for right now. The first case study should be out in a few days.