Educational Tips

I'd like to review the need for rib series x-rays. Rib series include 6 views. This is a pretty significant dose of radiation. Ergo, there are very specific criteria for when to order this test.

• Suspected fx's to ribs 1 - 2
• Suspected fx's to ribs 9-12
• Multiple rib fx's
• Preexisting pulmonary dz
• Suspected pathologic fx

Thus, a healthy 22 yo w/ mid-CW pain doesn't need a rib series. A simple two-view CXR will provide you w/ all the info that's clinically important. In fact, I think the above list might be a little liberal. What are the questions you really want answered? For me, I want to know if a) they have a PTX or b) is there a flail chest. Pulm contusion and other signs of trauma will show up on the CXR. We don't typically see ribs 1 or 2 fx'd b/c it's typically from high-velocity trauma. Our usual pt population has rib fx's from 4-10. If there is a flail chest, I think most of it will see it on a CXR. And once a flail chest is diagnosed, what are the extra views going to tell you? I haven't dx'd a PTX w/ a rib series but missed it on a CXR.

So the next time you plan to order a rib series, ask yourself the question: will I be able to see what clinically matters on a two-view CXR and does the pt really need those extra views?

One other topic I'd like to touch on is when do you order a U/A in a febrile child without an obvious source of ifx? Remember that there's a much higher propensity of UTI's in females. A rule that I utilize for my patients who don't have a significant h/o UTI's/pyelo is the following:

• Current recommendations say to check a U/A in any female pt less than 2 years. I will check a U/A in a female older than this b/c of it's frequency.
  
• Circumcised males- I don't check a U/A in boys older than 6 months old. This I adhere to.
• Non-circumcised males- I don't check a U/A in boys older than 12 months old. Again, I follow this policy.

I'd be interested in what other people do and their rationale. Josh- what's your algorithm?

December Abstracts

Here are the December Abstracts. Swish them around your mouth to appreciate their heady goodness... Please appreciate the first study reviewed.

• Melniker, L.A., LEIBNER, EVAN (AKA "THE LITTLE BALL OF HATE") et al, Ann Emerg Med 48(3):227, September 2006: RCT of FAST scan in ED for trauma pts. Of note copa was one of the sites involved. Admission dates were 4 days shorter and lower complication rates. A nice paper and really supports the use of FAST scans and it seems to change outcomes. Let us support the best 2nd author ever, this is a very important and well-thought of study. I'd be interested in this nerd to give his take home points from this study...
  
• Malangoni, M.A., et al, Ann Surg 244(2):204, August 2006: RCT of Zosyn vs Augmentin vs. Moxifloxacin (Avelox) for trx of complicated intraabdominal infections. These would include percutaneous drainage or surg. Study done at the prestigious Case Western Reserve University. This study had some data snooping, but the bottom line is they all worked about the same. Nothing out of this study that would really change our management.
• Gallagher, E.J., et al, Ann Emerg Med 48(2):150, August 2006: Use of morphine in acute abdominal pain. They were randomized to Morphine 0.1 mg/kg (max of 10 mg) vs placebo. The bottom line is the morphine helped w/ the pain, but it didn't hurt the ability to accurately diagnose the underlying etiology. Pretty intuitive stuff that won't change our trx.
• Turnipseed, S.D., et al, Acad Emerg Med 13(9):961, September 2006: A study that looked at the ability of ED docs vs. cardiologists to differentiate STEMI and benign early repolarization. They theorize that it exists in 1% of the population and usually in a younger population. The concern is inappropriately giving thrombolytics to a patient with early repolarization. Of course what is the gold standard for early repolarization? Also you have to take the whole clinical picture: history, risk factors, etc.
  
• Schuijf, J.D., et al, Am J Card 98(2):145, July 15, 2006: Another study looking at the use of CTA (64 slice) for CAD. They compared it to angiography and this was in pts w/ known CAD. Sensitivity was 86% and specificity 98%. The big concern is false positive results that end up in unnecessary angiograms. I discussed this in the November abstracts.
• Chase, M., et al, Ann Emerg Med 48(3): 252, September 2006: Validation of TIMI scores in ED CP pts. Interesting to note that of the nearly 1000 pts admitted, only 4% had MI's and only 15% had ACS. The higher the TIMI score, the higher possibility of ACS. However, there were pts w/ TIMI 0 scores who had AMI (to scare you).
• Kosowsky, J.M., et al, J Emerg Med 31(2):147, August 2006: Use of BNP in ED. I don't know how many studies have been reviewed on BNP, but I almost never order this test anymore (refer to many old abstracts to understand the rationale). The bottom line is if you think it's CHF and it looks and smells like CHF, it's CHF. Why do the BNP? Is it going to change what you do?
• Sanchez-Fructuoso, A.I., et al, Ann Intern Med 145(3):157, August 1, 2006: Looked at out-of-hospital CPA and see if they'd be viable options for kidney donation. Graft survival was nearly the same if CPR was initiated quickly. You can open up a can of worms w/ regards to calling codes quickly and then wanting to harvest organs. Might be tough to pull off.
• Li, X., et al, Resuscitation 70:31, July 2006: A study that examined CPR +/- thrombolytics. However a recent European study that will be published has looked at the same trx and found no benefit. Ergo, the patient is dead, do you really want to push a $2000 drug to keep them dead?
• Ridker, P.M., et al, JAMA 295(19):2270, May 17, 2006: Studies that are sponsored by drug companies have a 20% more likelihood of being having a positive result. Tie this in w/ the positive study publication bias and you end up w/ bad studies being published.
• Morrison, L.J., et al, N Engl J Med 355(5):478, August 3, 2006: A rule for terminating out-of-hospital CPR. If you have no spontaneous return of circulation, the arrest is not witnessed, and shocks are not administered. If they had applied these rules and terminated CPR, however three patients who walked out of the hospital neurologically intact would have had their efforts terminated. Ergo not a perfect system yet.
• Soustiel, J.F., et al, Acta Neurochir 148(8):845, August 2006: Hyperventilating pts to a PCO2 of 32% and mannitol for elevated ICP. Bottom line is hyperventilation provides a minimal decrease in ICP but it also decreases CPP. The only real time to still hyperventilate someone is in the process of active hernation, then it'll drop the ICP the quickest. However in the long term, use mannitol.
• Mellick, L.B., et al, Headache 46:1441, October 2006: Trx of H/A in the ED using lower cervical IM bupivicaine injections. You inject them in the paraspinal musculature 1.5 cc, 2-3 cm lateral of C6-C7, about 1.5 '' deep using a 25g needle. They didn't distinguish what type of H/A it was. Complete relief was found in 65% (pretty impressive). There was no placebo and future studies will be needed, but something of interest.
• Dubos, F., et al, Arch Dis Child 91(8):647, August 2006: A French clinical analysis to differentiate aseptic meningitis and bacterial meningitis. There 100% sensitive rule included having > 1000 polys in the CSF. If I see > 1000 polys in the CSF, I don't need a rule to say it's bacterial meningitis.
• Boyle, A., et al, Emerg Med J 23:604, August 2006: A British paper that looked at DV and self harm. There is an association b/w the two.
• Misra, U.K., et al, Neurology 67(2):340, July 25, 2006: Indian study that examined the use of IV valproic acid vs dilantin for status epilepticus. Of note they didn't utilize benzos. Valproic acid did a little better than dilantin, but in the US, benzos are first line trx for status. Thus it won't change practice.
• Weintraub, M.I., et al, Stroke 37:1917, July 2006: The author looked at legal cases of the use of tPA in acute CVA. 8 of the 9 legal cases were for NOT giving tPA. 5 of the 8 had defendant verdicts. I've discussed this topic in prior abstracts, so I won't rehash all of it.
• Moran, G.J., et al, N Engl J Med 355(7):666, August 17, 2006: A look at the incidence of MRSA in the ED. 60% of skin and soft-tissue ifx are MRSA now. The key is to review our Abx sensitivities for the hospital and realize clindamycin is more and more resistant.
• Petersen, L.A., et al, Ann Intern Med 145(4):265, August 15, 2006: There appears to be no affect if "pay-for-perfomance" in healthcare. People could also select easy patients or alter the diagnosis to affect their bottom-line.
• Everitt, H.A., et al, Br Med J 333:321, August 12, 2006: There's a marginal benefit in topical Abx vs no trx in infectious conjunctivitis. While I'm all for more conservative trx and withholding Abx in viral situations, I don't forsee anyone not giving the Rx or changing their management.
• Candy, D.C.A., et al, J Ped Gastroenterol Nutr 43:65, July 2006: The use of PEG + electrolytes for fecal impaction in pediatric population. There was success in 92% (vs. the Barrali preferred digital route).
• Katchman, E.A., et al, Am J Med 118(11):1196, November 2005: Authors go back and review the trx of cystitis w/ 3 days of Abx. Longer trx causes higher risks of diarrhea, adverse events, etc. Cure rates are a little better, but higher complication rates. No need to change trx.
• Pannu, N., et al, JAMA 295(23):2765, June 21, 2006: IV contrast nephropathy and prophylaxis. Not much to change your trx- hydrate them, use as little as you can and use NAC if you need to.
• Ho, K.M., et al, Br Med J 333:420, August 2006: Use of lasix to trx ARF. No difference if you used lasix. Increased ototoxicity, but no improvement- thus don't bother using it.
• Safdar, B., et al, Ann Emerg Med 48(2):173, August 2006: Use of renal colic w/ Morphine + toradol vs either morphine or toradol alone. They used a small dose of morphine (5 mg IV). Morphine works in 5 minutes, toradol takes 20-30 minutes. If you want to give an NSAID, any other works just as well as toradol w/ less side affects.
  
• Porpiglia, F., et al, Eur Urol 50(2):339, August 2006: They evaluated the use of alpha-blockers (Flomax), steroids or both for distal ureteral stones > 5 mm. The bottom line is the combo worked in 85% in the first 10 days. 60% who got nothing passed their stones as well. I'm not adding steroids, but will continue flomax as an outpatient per urologists requests.
• Hollingsworth, J.M., et al, Lancet 368(9542):1171, September 30, 2006: Meta-analysis for alpha-blockers or Ca-channel blockers for stone passage. Small numbered study w/o good methods. Nothing here will change trx.
• Abdel- Wahab, O.I., et al, Transfusion 46:1279, August 2006: Reversal of elevated PT w/ FFP. The study sample however only included pts w/ a mild bump in their INR. In fact the highest INR was only 1.8. I wouldn't start pushing FFP for that small increase. Not a good paper.
• Kawai, N., et al, Clin Infect Dis 43:439, August 15, 2006: Japanese study that looked at Tamiflu for Influenza A and B in pediatrics. The patients in the influenza A group did better (fever for 2 days less) but no change in the influenza B group. Not a RCT.
  
• Williams, R., Emerg Med J 23:473, June 2006: Remember on pediatric spiral tibial fx's to look or signs of abuse.
• Chang, A.K., et al, Ann Emerg Med 48(2):164, August 2006: Dilaudid vs Morphine for acute pain. There was equivalent pain relief b/w the two drugs if you give them equivalent doses.
• Kearney, P.M., et al, Br Med J 332:1302, June 2006: BMJ study looking at COX-2 inhibitors and risk of CAD. They do cause an increased risk. NSAIDs are safer for GI side effects, but both can cause atherothrombotic dz.
  
• Martinon-Torres, F., et al, Resp Med 100(8):1458, August 2006: Nasal CPAP and heliox were utilized in PICU pts w/ RSV bronchiolitis. All measures were better in this small study.
  
• Waterer, G.W., et al, Chest 130(1):11, July 2006: Delayed administration of Abx in community-acquired pneumonia. Delay in Abx was associated w/ atypical presentation. Not much else to know and pretty logical.
• National Heart, Lung and Blood Institute ARDS Clinical Trials Network N Engl J Med 354(16):1671, April 20, 2006: Use of steroids in persistent ARDS. Bottom line is solumedrol is not beneficial.
• Arroll, B., et al, Br Med J 333:279, August 2006: Study looking at Abx in acute purulent rhinitis. Number-needed-to trx was 7-15. Nothing here of significant note.
• Melniker, L.A., et al, Ann Emerg Med 48(3):227, September 2006: RCT of FAST scan in ED for trauma pts. Of note copa was one of the sites involved. Admission dates were 4 days shorter and lower complication rates. A nice paper and really supports the use of FAST scans and it seems to change outcomes.
  

That's it for this month. There will be a short blog coming out soon on a couple educational topics, so keep your eyes out for those.