Trigger Point Injections

• A simple and easily learned procedure for trigger point pain is a trigger point injection. If you have never performed one before, feel free to ask me for an easy demonstration. Here I'll walk you through the diagnosis and treatment of trigger point pain.
• Trigger point pain is myofascial pain that can be due to strain or poor posture with nerve irritation.
  
• Cummings and White did a review of 23 studies. They determined that none of the studies had enough quality to demonstrate or refute the benefit of this technique. From the Mattison Journal of Anectdotal Evidence, I have yet to perform a trigger point injection that didn't provide nearly total pain relief within a couple of minutes of the injection and dramatic pain relief at time of discharge.
  
• Typical areas of trigger point pain are the trapezius muscle, occipital, rotator cuff, lateral epicondylitis and femoral-trochanteric pain. I for one only feel comfortable injecting the trapezius region. On average, I see patients with this kind of pain once every couple of months. Therefore, I will only discuss this particular location.
• The easiest way to diagnose trigger point pain of the trapezius is based on history and a very simple technique. Typical historical complaints include overuse patterns, sleeping in an "uncomfortable" position, etc. Patients will have pain in their trapezius region that sometimes will refer discomfort down their shoulder/upper extremity.
• Physical examination may reveal a "knot" or muscle spasm of the trapezius.
  
• The clincher in making this diagnosis is reproduction of symptoms with the patient or physician palpating the area of question with one finger. I'll simply ask the patient to use their finger or my finger to find the one area that when palpated reproduces maximum discomfort. I then mark it with a pen. This typically is found near the mid-clavicular line deep in the trapezius.
• The next step is to order kenalog 40 mg from the pharmacy. This is usually the longest delay.
• I'll create a cocktail of kenalog 40 mg + bupivicaine 0.25% (usually 5 cc). I might include a little lidocaine with epi for quick acting effect. I usually create a small wheal with a 25 g needle and then switch to a 22 g in order to deliver the medicine a little deeper. I usually only go 1-2.5 cm. This may vary depending on patient's habitus, muscle mass, etc. Obviously the complication to avoid would be a pneumothorax. Other complications are infection (use aseptic techniques obviously).
  
• After the injection, patients usually have pretty dramatic relief within five minutes. The bupivicaine provides longer lasting effects. The kenalog usually will provide relief for several days to weeks. Typically after this duration the patients symptoms have resolved.
• The obvious benefit of this procedure for patients is pain relief without the need for narcotics, muscle relaxants, etc. Patients are usually very thankful and satisfied with the procedure. The benefit to us is pain relief for the patient and a simple procedure that is billable (we can't always be altruistic).
  
• If you have any questions about this procedure or want to know more about it, let me know. Hope this helps.
  

August Abstracts

• I'll post the question now- would it help if I emailed out a copy of these abstract reviews to the group as well as publishing them on the blog? Would that help with people reading them? If you feel strongly let me know... Now on to the fun.
• Lee, S.Y., et al, Emerg Radiol 12(4):150, May 2006: Another study that shows you don't need to add contrast for CT Abd/pelvis to diagnose appys or diverticulitis. They actually scanned them both with and without contrast (extra dose of radiation). Contrast didn't change the ability to find anything signficant. We need to bundle these and slip them under radiology's door.
• Mitchell, A. M., et al, Ann Emerg Med 47(5):438; May 2006: Pre-test probability assessment of ACS- Three academic ED's utilized looking at 45 day outcomes in patient with ACS. Very sensitive scores including ACI-TIPI - 100% sensitive but only 6% specific. Unstructured clinical judgment does better than using ACI-TIPI scores. Any comments B-Tiff?
• Yusuf, S., et al, New Engl J Med 354(14):1464, April 6, 2006: NSTEMI pts (576 centers) - that used fondaparinux that is compared to lovenox. No difference in primary outcome (death, MI or refractory ischemia). There was an improvement at 30 days but only 2.9 vs 3.5% with a number need to treat at 176 (and not statistically significant). Some data snooping. The real conclusion is that it was non-inferior to placebo (very supportive, slight sarcasm). Sponsored obviously by the drug company that manufactures it.
• The OASIS-6 Trial Group JAMA 295(13):1519, April 5, 2006: Use of fondaparinux in STEMI patients in Europe. Treatment for STEMI different than in the US (only 25% got PCI, about 50% got lytics). Compared fondaparinux to placebo. Death and reinfarction was better in the fondaparinux group (number need to treat was 76). The primary end point was not statistically significant.
• Boersma, E., et al, Eur Heart J 27(7):779, April 2006: This pools studies looking at PCI vs. lytics. 25 RCT's with meta-analysis. Delays were associated with worse outcomes. PCI is better than thrombolysis, even when you add in time-differences. Mortality for lytics was 6% if given within one hour (have your MI at the hospital) and 12.7% if after 6 hours. PCI had 4.7% mortality when less than one hour vs. 8.5% when delayed.
• Curtis, J.P., et al, J Am Coll Card 47(8):1544, April 18, 2006: Pre-hospital EKG- Compared pts who didn't get pre-hospital EKG that got PCI or lytics. 5-8% who got pre-hospital EKG got quicker PCI (by 20 minutes) and 10 minutes faster for lytics. The bottom line is there actually doesn't show a significant benefit to pre-hospital EKG's when you look at the actual number that benefits vs. the number of people who present with CP.
• Wright, R.S., et al, Internat J Card 108(3):314, April 2006: A study looking at the benefit of statins given in the first 24 hours. This wasn't randomized and there were differences in baseline characteristics between the two groups. Pts receiving statins had a lower mortality -however their group had smaller MI's and less frequently CHF. The benefit was more of an association than due to randomization of the study. Several studies have been touting use of statins within 24 hours. Something to consider.
• Mueller-Lenke, N., et al, Heart 92:695, May 2006: The use of CXR in diagnosis of CHF. The study is sponsored by a Swiss company who sells the BNP test. Nothing really of benefit.
• Abu-Laban, R.B., et al, Lancet 367:1577, May 13, 2006: The use of theophylline in CPA. 971 patients with asytole or PEA who had been treated with ACLS without success. Patients were randomized to continued ACLS or theophylline. Return to spontaneous circulation, survival, etc (all major end factors) shows no difference. Your chance of walking out of the hospital in either group in less than 0.5%. So Bob, quit administering theophylline boluses during your codes...
• McGillicuddy, D.C., et al, Ann Emerg Med 47(4):390, April 2006: Remember Guillain-Barre has ascending weakness with paresthesias and a loss of DTR's. Also there is the Miller-Fischer variant which can have bulbar involvement. Botulism is weakness that starts at the head and descends.
• Whiting, P., et al, Br Med J 332:875, April 2006: They looked at 29 different studies in the diagnosis of MS. In the better studies, MRI is not the gold standard and doesn't always make the diangosis of MS. The poorer studies are the ones that showed a stronger support for using MRI. Not much that will change your practice. If you're concerned, I think most people will still get the MRI.
• Crandall, C., et al, Acad Emerg Med 13(4):435, April 2006: They looked at patients who had presented to the ED with SI or gestures. It didn't matter if it was an OD, self-harm or SI. They followed over 218,000 pts for 6 years after presentation to the ED with these complaints. Of the patients who died, 6.9% were due to suicide. Bottom line, is you can clear them early on, but they have a much higher rate of death due to suicide later/
• Sheth, R.D., et al, Arch Neurol 63:529, April 2006: Protracted ictal confusion in the elderly. This is a chart review of 22 elderly patients with protracted confusion. They were attributed to partial, complex status epilepticus. Most patients had delayed diagnosis. You don't have to have abnormal movements, but it can simply be confusion or AMS. Interesting to note given all the elderly patients we see with AMS. The only way to diagnosis it is a stat EEG (sounds easy enough...)
• Hill, M.D., et al, Stroke 37:1137, 2006: Patients with TIA's should be admitted to the hospital. The 90 day risk of CVA is 10-20%. In theory, if you could do rapid outpatient eval (echo, duplex carotid U/S, MRI, etc) you could send them home and have it done in 1-2 days. That's usually not feasible and I've never had a hospitalist refuse an admit for a TIA- so just bring them in (standard of care).
• Trivia for you, lipitor is the most commonly prescribed drug in the world. Plavix is #2....
• Tayal, V.S., et al, Acad Emerg Med 13(4):384, April 2006: U/S use by ED docs in cellulitis to r/o fluid collections. Trx was changed in 56%. Again, another nice use of the sono-site.
• Richardson, D.B., Med J Australia 184(5):213, March 6, 2006: An Australian study looking at patients who had been seen in an ED during an "overcrowed" shift. These patients got "worse" care with 0.42% mortality after 10 days (during crowded days) vs. 0.31% for patients seen on non-crowded days. Essentially 1 out of every 1000 patients seen during an "overcrowded" day will die due to poor care.
• Choi, Y.F., et al, Emerg Med J 23:262, April 2006: A study that looked at doctors seeing patients (in a Hong Kong ED seeing 400 pts a day). They did it for 7 consecutive day shifts with a doc out in triage ordering (similar to our yellow-pod). They dispo'd 10% of patients right there (admit or d/c). I think we've seen from our own trial the benefit of having a doc out there.
• Patel, A.H., et al, Can Med Assoc J 174(7):917, March 28, 2006: A Canadian study looking at glycemic control of ICU patients. Of course you can either look at it in the way that either good BS control improves outcome or is it that sicker patients, with more serious problems end up having higher blood sugars (and sicker patients do worse). Current recommendations have been to keep the BS less than 110. Prior studies have not been as supportive of this strict BS control.
• Freedman, S.B., et al, N Engl J Med 354:16, 1698, April 20, 2006: 215 peds patients with clinical gastroenteritis and mild to moderate dehydration. They were randomized to zofran vs. placebo followed by oral rehydration. 14% w/ N/V after zofran vs. 35% in placebo.
• Katz, S.I., et al, Am J Roent 186(4):1120, April 2006: They looked at the radiation dose people got (non-contrast) CT for renal colic. One patient got 18 CT's in one year. The estimated exposure for patients receiving over three CT's was equivalent to the radiation exposure of survivors of atomic bombs in Japan. Very interesting info.
• Bernard, A.W., et al, Emerg Med J 23:302, April 2006: CBC and retic count in sickle cell crisis. They didn't have any indicator for infection. Expect a high WBC in sickle-cell crisis (due to demargination). In children it's important to r/o aplastic crisis.
• Singh, G., et al, Am J Med 119(3):255, March 2006: Randomized patients b/w diclofenac, celebrex and naproxen for musculoskeletal pain. Ibuprofen has the lowest toxic profile. The bottom line is that there isn't a statistical difference between the drugs and GI side effects. Ibuprofen works just as well, is much cheaper and has a similar side-effect profile.
• Apter, A.J., et al, Am J Med 119(4):354.e11, April 2006: This is a big topic of interest to me- the use of PCN vs. cephalosporins. People who had a reaction to PCN were more likely to have a reaction to cephalasporins. Oh, yea- they were just as likely to have a reaction to sulfas, and every other Abx/meds. Patients who are PCN allergic CAN receive cephalasporins. The bottom line is that originally when they were made they had a similar preservative. Now preparations are different and the chance of cross-reactivity is 0.0005%. This is a favorite of mine to educate patients and nurses about (and now you know if you didn't).
• Parlak, M., et al, Acad Emerg Med 13(5):493, May 2006: A Turkish study that looked at induction agents prior to cardioversion comparing Versed to propofol. The induction time was the same, but the recovery time was substantially longer (18 minutes in propofol vs. 54 minutes in Versed). There was no change in hemodynamics between the two groups. Bottom line, if you're going to spark them up, use propofol if you can.
• Denmark, T.K., et al, J Emerg Med 30(2):163, February 2006: A case-report of ketamine in the use of two pediatric patients with significant asthma. If they're that bad (to be on a ketamine gtts), they need to go to a PICU (from our standpoint). If you have to intubate a bad asthmatic (one of the worse things you can do to a bad asthmatic) is to use ketamine as an induction agent.
• Kabrhel, C., et al, Acad Emerg Med 13(4):471, April 2006: PE vs. the most-likely diagnosis. ED docs filled out a form that listed the 10 most likely diagnosis when ordering a test to r/o PE. When you figured PE was the most likely diagnosis- it was 20% of the time. When you figured it was a viral syndrome, anxiety, (low prob patients), they had it only 1% of the time. When you thought it was ACS (and other bad things), it still was PE 20% of the time. Clinical judgment is better than the Well's criteria (see prior blogs about this).
• Hope this helped. I have a couple of other updates in the works...