Tuesday, August 22, 2006

July Abstracts

  • Diercks, D.B., et al, Am J Card 97(4):437, February 15, 2006: From the CRUSADE database, this looked at EKG's done in non-ST elevation ACS; 35% received an EKG in less than 10 minutes. They showed that pts who did not present w/ whopping STEMI's did not do worse despite delayed door-to-EKG time.
  • Marill, K.A., et al, Ann Emerg Med 47(3):217, March 2006: This study investigates the use of amiodarone in the use of trx of monomorphic V-tach. Small N (33), but amiodarone didn't seem to be very effective in the termination of V-tach (only 29%). The authors feel that sedation and cardioversion is better at termination of stable V-tach, than amiodarone.
  • Vukmir, R.B., et al, Am J Emerg Med 24:156, March 2006: They examine the effects of sodium bicarb in the treatment of prolonged, pre-hospital cardiac arrest. This was a prospective, RCT that showed a significant difference in survival (defined by arriving to the hospital alive) - 32.8% vs. 15.4% in controls in the bicarb group when looked at the prolonged arrest subset (greater than 15 minutes). HOWEVER, the overall survival rate involving all groups was 13.8 vs 13.9%. Ultimately, i don't think this should change your management. Their definition of survival isn't clinically meaningful and the subset that did better (prolonged - i.e. > 15 minutes) may simply be more likely to make it to the hospital b/c they had something salvageable that EMS was working on prior to presenting to the ED.
  • Decker, W.W., et al, Ann Emerg Med 47(3):237, March 2006: A practical article that looks at pts w/ asymptomatic HTN. Criteria was SBP > 140 or diastolic > 90. This demonstates that treatment of asymptomastic HTN (not urgency or crisis) is ACTUALLY UNNECESSARY AND MAY BE HARMFUL. as long as the patient has close follow-up, the patients do better if you hold treatment. Rapid lowering of BP is deliterious to patients. Even agents such as CCB's and Clonidine may provide too much of a drop of BP. This is a pretty important study w/ regards to our practice.
  • Bramwell, K.J., et al, Ped Emerg Care 22(2):90, February 2006: A small study that examined the effects of etomidate in ICP and SBP of pediatric trauma pts w/ severe head injuries. Etomidate did lower the ICP without a significant change in MAP, and actual increase in CPP. this would not change our use of etomidate in this scenario and still an excellent induction agent in trauma pts.
  • Thomalla, G., et al, Stroke 37:852, March 2006: A German multi-center trial that examined the use of tPA in pts w/ an ischemic CVA up to 6 hours after the onset. This study utilized MRI's to select an appropriate subset of pts who would benefit from tPA. 174 pts were enrolled and 66 received trx b/w 3-6 hours. Pts who had delayed tPA (3-6 hours) had ICH in only 3% (lower than the total population). there is some data mining and change in what NINS looks at. hold of on tPA's pts right now (as the most recent studies show that people do worse w/ it).
  • Bateman, B.T., et al, Stroke 37:440, February 2006: A multi-center study that examined the use of tPA in ischemic stroke. (N=248,964). 1% of these pts received tPA. Mortality was higher in pts w/ tPA (10.2% vs. 6.7%). Again, a higher mortality in tPA pts.
  • King, M.D., et al, Ann Intern Med 144(5):309, March 7, 2006: The authors examined MRSA in the community. Abx that were typically sensitive to Vanc, Bactrim, Rifampin, Clinda (much more effective than our usual rates in-hospital).
  • Ligtenberg, J.J.M., et al, Intens Care Med 32(3):435, March 2006: They examined the control of glucose in "mixed" ICU pts. Lately the thrust has been to keep very strict BS control. However, this did not show any relationship b/w BS control and mortality. They had small numbers, but goes against the grain of the recent literature. What may be more of the case, is that sicker pts have higher BS's and ultimately sicker pts have higher mortality rates. i don't think it'll change your management, but something to be aware of.
  • Sheikh, A., et al, Br J Gen Pract 55:962, December 2005: Why trx acute conjunctivitis w/ Abx? Usually it's viral right? well this study examines that question w/ a meta-analysis. they showed limited efficacy. of course, are you willing to not use Abx for a probable viral conjunctivitis in a parents' child when any bad outcome is so serious? tough to stop over-treating these in my opinion.
  • DeZee, K.J., et al, Arch Intern Med 166:391, February 27, 2006: A study from the army that shows the use of Vit K in reversal of coumadin coagulopathy. IV reversal is the fastest but PO is probably the best. use a smaller dose b/c over-reversal will cause in significant delays in getting them back to therapeutic. a good oral dose is 1-2.5 mg PO. if they're hemorrhaging than use FFP. i think this is a good study to note when admitting pts w/ coumadin coagulopathy and need for reversal. also of note bactrim can sigificantly alter INR's in pts on coumadin.
  • Committee on Infectious Diseases Pediatrics 117(3):965, March 2006: As I've described earlier in the blog, there's new recommendations coming out with regards to the acellular pertussis vaccine to be included in the Td vaccine (Tdap). Any child less than 6 months old (who has never had immunizations) or any child 11 years or older needing a booster SHOULD receive the Tdap vaccine.
  • Halperin, S.A., et al, Ped Infect Dis J 25(3):195, March 2006: Tdap vaccinations may be given safely to patients who have received their last Td shot even as recently as two years ago. There was not any increase in arthrus reactions seen with the Td vaccine.
  • Pitt, E., et al, Emerg Med J 23:214, March 2006: A British prospective trial that demonstrated triage nurses who utilized NEXUS criteria would be able to safely clear patients from c-spine precautions. They were able to clear patients of their c-collars 20 minutes on average sooner than physicians (they cleared roughly 50% from c-collars without x-rays). A low-powered study, but it would be interesting to consider whether it'd be feasible to educate our ambo nurses how to clear patients from c-collars and back boards (something we all agree doesn't take a lot of intellect- just common sense).
  • Fan, J., et al, Acad Emerg Med 13(2):153, February 2006: A RCT in a Canadian ED looking at whether patients with ankle injuries would have shorter stays if a triage nurse utilized the Ottawa Ankle Rules (OAR) when triaging a patient versus the control group (usual triage scenario). There was no difference in length of stay and other important factors.
  • Finckh, A., et al, Spine 31(4):377, February 15, 2006: A double-blinded Swiss trial looking at the use of IV glucocorticoids in sciatica. They gave a dose of Solu-Medrol 500 mg IV (big dose). After three days there was no clinical difference. Only 65 patients enrolled, so a low-powered study.
  • Plint, A.C., et al, Pediatrics 117(3):691, March 2006: Pediatric patients randomized to a removable plaster splint vs. plaster cast in buckle wrist fractures. There were no adverse outcomes and some children with casts had to return for issues. The benefit of this treatment is that kids could remove the splints to take a bath, etc. This seems intuitive and reasonable. It'd be something interesting to discuss with Motzkin et al, and see if we could change our ED management of these stable fractures.
  • Bradshaw, M., et al, Emerg Med J 23:210, March 2006: A RCT of the routine use of anti-emetics with morphine vs. morphine. I see this practice too often in the ED. If the patient doesn't have N/V, then why bother giving them an empirical dose of phenergan, etc? Well this study proved that point. There was no difference in the groups and empiric doses of anti-emetics can cause adverse effects (dystonic reactions, etc). Bottom line is, if they have N/V, then give them something. If they're having N/V with pain, then give them something. But if they just have pain and no N/V, then hold the anti-emetics. A good study and one that people should be aware of.
  • Lucha, P.A., et al, Am Surg 72:154, February 2006: Narcotics administered to patients during an acute painful crisis were still able to be competant and sign provide informed consent (unless they're comatose obviously).
  • Heinz, P., et al, Emerg Med J 23:206, March 2006: Atropine isn't required to be given concominantly with ketamine in pediatric patients. It can cause an increased HR and isn't necessary.
  • Hoffman, R.J., et al, Am J Emerg Med 24:139, March 2006: Ideal ETT cuff pressure should be 15-20 cc H20. Experienced ED docs (do more than 25 tubes a year) were very bad at estimating the cuff pressure on preinflated cuffs. The bottom line- we typically overinflate cuffs and this will cause tracheal mucosal trauma and ischemia. Palpation of the cuff is not sufficient and we need to look at an accurate means of measuring cuff pressure accurately.
  • Scolnik, D., et al, JAMA 295(11):1274, March 15, 2006: There is no benefit of humidified air in the treatment of acute moderate to severe croup in the ED. Give them there steroids and vaponephrin if they need it. Interesting to note before the croup season kicks in.
  • Humair, J.P., et al, Arch Intern Med 166:640, March 27, 2006: Centor criteria in acute pharyngitis looking for GABHS followed by RSA and throat culture. They excluded those with 0-1 of the Centor criteria. They looked primarily at those with 2-3 criteria. I still recommend if they have 4 criteria- treat them. If they have 0-1 the chance of them having it is very low. In 2-3 criteria, if you feel the need, RSA and only treat if positive.
  • Orlinsky, M., et al, Am J Emerg Med 24(2):233, March 2006: You do not need to get x-rays on every glass-induced lac. In a superficial lac you should be able to determine whether there's any glass. On deep lacs, you need the x-ray. On the superficial wounds that you can adequately explore you don't need an x-ray. Even if you miss a small 1 mm piece, there's a good chance you're not going to find it and if it's an location that isn't clinically siginificant (soft-tissue away from nerves and vascular structures), it shouldn't cause any problems if you do miss it.


Blogger PMac said...

With regards to the Sodium Bicarb - is this study similar to the Amiodarone - that it wasnt powered enough to find an overall survival benefit, but just enough to find a difference in arriving to the hospital?

Nice reviews

10:33 PM  

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