Wednesday, March 07, 2007

February Bites

More goodies on the way. Enjoy with a heady cheese...
  • Ranji, S.R., et al, JAMA 296(14):1764, October 11, 2006: Another article on what should be a dead topic by now- opioids don't affect the surgeon's abdominal exam in the ED. Not an issue for me when we're not dealing w/ residents and our relationship w/ the surgeons. Next...
  • Salim, A., et al, Arch Surg 141:745, August 2006: Analyzed the utility of CT scans in the anterior abdominal stab wounds. Old lore stated that these were either explored by the trauma surgeons in the trauma bay or just go to the OR for a ex lap. The question is can we just CT them and does that assist in saving the pt from an OR visit? Quite a few false positives in a limited sample size. It'd be better if this was an RCT and they involved FAST scan as well (if you're looking for blood perhaps you'd see it on the FAST scan and don't need the CT, etc.). Not a great study and not horribly applicable in the community non-trauma center setting.
  • Dewey, M., et al, Ann Intern Med 145(6):407, September 19, 2006: Looked at the dx of CAD using either CTA or MRA. The CT delivered the same amount of radiation as an angiogram. Pts undergoing MRA had a lot more issues w/ claustrophobia, metal implants, etc. The problem is neither study had good enough likelihood ratios and low specificity. 1 out of 4 pts were false positives and ended up getting needless caths. False positives will also be an issue w/ these tests.
  • Mahajan, N., et al, Internat J Card 111:442, August 2006: Retrospective study analyzing elevated troponin's and the fact that they're not synonymous w/ AMI. 18,000 patients from a database who got an angiogram were used. Their fundamental gold standards for AMI was based on CAD on the cath (not the best measure). The bottom line is yes, there are other conditions that cause a bumped troponin. Nothing here will change your practice.
  • Stenestrand, U., et al, JAMA 296(14):1749, October 11, 2006: Swedish study that looked at the difference b/w PCI, pre-hospital thrombolysis and in-hospital thrombolysis. PCI was the best. 4% increased mortality in the in-hospital group vs. pre-hospital setting (interesting to note). Bottom line for us, PCI is the best and our current standard of care. Perhaps the in-hospital group was too sick to go to PCI or receive it in the field.
  • Caglar, S., et al, Am J Emerg Med 24:655, October 2006: ED pts who were admitted who were sent to radiology suite on monitors. They were looking for life-threatening arrhythmias. None occurred. Bottom line, it's safe to send them off monitors.
  • Kottke, T.E., et al, Am J Prev Med 31(4):316, October 2006: Bottom line is available AED's, ICD's and eating omega-3 fatty acids will decrease your risk for sudden cardiac death. thank you good night.
  • Leung, J., et al, Ann Emerg Med 48(5):540, November 2006: Australian study for U/S guidance for IJ line placements. bottom line- better success, quicker, less complications. if you're going there, use the U/S.
  • Dunning, J., et al, Arch Dis Child 91:885, November 2006: British study looking at pediatric closed head injuries. They tried to come up w/ an algorithm for which kids should get a head CT. They have a lot of variables (14- very difficult to use in the ED). If you had any one of the 14 findings should have a head CT.
  • Gardner, P., N Engl J Med 355(14):1466, October 5, 2006: Prevention of meningococcal dz. Transmission is respiratory. High risk are infants, barracks, dorms, asplenic, travelers to endemic areas. Give post-exposure prophylaxis to appropriate w/ Abx within 24 hours of identifying the case. You need at least 8 hours of close contact, intubated them, got coughed on, etc. Everyone else really doesn't need prophylaxis.
  • Perry, J.J., et al, Stroke 37:2467, October 2006: Spectrophotometry for diagnosis of SAH. It can have a high false positive rate. Warning leaks usually will have a negative CT head. In this study they only picked up 1 SAH w/ CT/LP out of 200.
  • Lavi, R., et al, Neurology 67:1492, October 2006: Use of standard vs. Whitacre needle in LP. Post LP H/A rate up to 40% (i usually cite 10%). They utilized 22g vs 22g Whitacre. Post LP H/A was 36% w/ traumatic needle and only 3% w/ Whitacre. Most significant risk factor for LP H/A is the needle you use. Neurologists recommend using the Whitacre. This will save another visit, blood patches, etc. Bottom line, this probably should be and will be the standard of care. Evan, Paul, Judy, comments?
  • de Bruijn, S.F.T.M., et al, Stroke 37:2531, October 2006: TEE were better than transthoracic echo (TTE) in work-up of pt's w/ TIA vs CVA. Cardiogenic emboli cause 20-40% of TIA and CVA. A lot of small clots found only on TEE. Are they clinically significant clots (i.e. one that would cause symptoms)? They were small atrial appendage clots found, so would these cause a TIA or CVA? don't have the answer.
  • Paydar, K.Z., et al, Arch Surg 141:850, September 2006: Looked at abscess s/p I&D and then sent home on Abx. They cultured the wounds. 2/3 were MRSA. MRSA pts's got a lot of keflex (ones that don't cover the bug that grew out). They followed these people and they did just as well. Truly you can just I&D them and go home w/o Abx. Even if it ends up being MRSA. Will that change what you do?
  • Campbell, E.M., et al, J Am Med Informat Assoc 13(5):547, September-October 2006: What happens w/ computerized order entry by the docs? They wanted to see what the unintended circumstances were. This paper has a lot of info reviewing what the effect of these systems had on the ED. Evan, you're the AV geek, you may want to review this paper.
  • Marin, J.R., et al, Ped Emerg Care 22(9):630, September 2006: FB removal for peds ear canal. 80% success in the ED. If you have to do more than one attempt, you probably won't succeed. If you can't get it right away, don't force it and give up and refer to ENT.
  • Germiller, J.A., et al, Arch Otolaryngol Head Neck Surg 132:969, September 2006: Intracranial problems w/ sinusitis. Epidural abscess was the big complication. Frontal sinusitis is worse than others and should be treated emergently. The frontal sinus has only a 3 mm wall, so easy extension into the brain. The venous system goes to the saggital system (hematogenous spread). Bottom line, is admit frontal sinusitis, IV Abx and ENT eval. Swelling of the sphenoid sinus can also cause irritation of CN V2 and give infraorbital anesthesia.
  • Maggiorini, M., et al, Ann Intern Med 145(7):497, October 3, 2006: Use of Cialis and decadron in high-altitude pulmonary edema (HAPE). Pulmonary vasodilators (cialis) to correct the hypoxic induced pulmonary vasoconstriction. Pts got Decadron 16 mg PO qd, Cialis or decadron. I have a feeling Barrali will be citing this paper for his next trip to Bhutan. Not much here that will help.
  • Doria, A.S., et al, Radiology 241(1):83, October 2006: U/S or CT in dx of appy in peds and adults. U/S dx'd 88% in peds and 83% in adults. CT was 94% in peds. You'll miss one appy for kids w/ U/S only in every 100. I know at PCH, we'd U/S the kids first to r/o appy. If positive, you're done and no radiation needed, drinking contrast, waiting 5 hours, etc. This would be a nice project to do w/ radiology. Age cut-off for ordering U/S in peds suspected appy's. Evan...
  • Szajewska, H., et al, J Ped 149:367, September 2006: Use of pro-biotics in prevention of Abx associated diarrhea in peds pts. 800 pts in RCT, 28% got diarrhea. 12% incidence in kids who got pro-biotics. 1 out of every 7 would benefit. I've never prescribed. Josh?
  • Lee, S.B., et al, Neurology 67:1272, October 2006: Chart review from the Mayo for intracranial bleed in pts on coumadin. Pts were given FFP and Vit K. 3 hour mean time to time to start the FFP, and it took 9 hours to get the FFP in. Took b/w 14-49 hours to normalize the INR. Takes a long time to reverse. Small study and chart review. Not much to take from the study.
  • Eichacker, P.Q., et al, N Engl J Med 355(16):1640, October 19, 2006: Reviewed the Surviving Sepsis Campaign. They ended up being very pro-Xigris and of course sponsored by the company that makes.... you guessed it. Nice commentary on this study and effect of drug sponsorship on research.
  • McGinley, J.C., et al, Am J Emerg Med 24:560, September 2006: Non-diagnosed elbow fx on cadavers. Would your management have changed on missing these small fx's. Coronoid fx's are important to catch.
  • Choong, K., et al, Arch Dis Child 91:828, October 2006: IV maintenance in peds - does it need to be D51/2 NS or can you just do NS? All of the old bad literature supported D51/2 NS. Bottom line, kids actually do a little better w/ NS as maintenance IVF of choice vs. hypotonic saline. Josh, comments?
  • Marco, C.A., et al, Acad Emerg Med 13(9):974, September 2006: Self-related pain scores- showed no correlation b/w triage V/S and patient reported pain score. Big surprise...
  • Powell, K.R., et al, Pediatrics 118(3):1287, September 2006: Use of systemic fluoroquinolones in peds (only allowed in kids for pyelo and anthrax, due to cartilage toxicity). In general still shouldn't use them in peds due to resistance issues.
  • Lindblad, C.I., et al, Clin Ther 28(8):1133, August 2006: Clinically important drug-disease interactions in elderly pts. 15% were admitted due to adverse effect of some drug.
  • Budnitz, D.S., et al, JAMA 296(15):1858, October 18, 2006: 0.6% of all ED visits are b/c of adverse effect of an outpt drug. 1 out of 6 of these patients needed to be admitted. Worse in elderly. The ones that have levels you can check usually cause the most problems.
  • Graham, D.J., JAMA 296(13):1653, October 4, 2006: COX2, NSAIDs, and cardiovascular risk. FDA whistleblower nails a drug company for minimizing the risk and ignoring data that they had.
  • Roback, M.G., et al, Ann Emerg Med 48(5):605, November 2006: IV vs IM ketamine in peds orthopedic procedural sedation. I personally refuse to use IM ketamine (prolonged half-life, varied effects, i want an IV always ready for any kid i'm sedating, etc. 35% incidence of emesis in IM dose, 18% in IV group. Increased sedation in IM group. Some will use IM and have no problems. I'm just a little more conservative.
  • Macie, C., et al, Chest 130(3):640, September 2006: Do inhaled steroids decrease mortality in COPD? no. pretty easy
  • el Moussaoui, R., et al, Chest 130(4):1165, October 2006RCT for trx of CAP. Pulmonary sx's resolved in 14 days, but people didn't return to baseline for 6 month. Interesting to note.
  • Sanabria, A., et al, World J Surg 30(10):1843, October 2006: Prophylactic Abx in chest trauma. Meta-analysis from 5 studies. Bottom line is there are old bad studies available. The best study showed no difference. No need for prophylactic Abx.
  • Chale, S., et al, Acad Emerg Med 13(10):1046, October 2006: Digital vs local anesthesia for finger lacs. They both worked about the same. Either is fine.
  • Liebmann, O., et al, Ann Emerg Med 48(5):558, November 2006: U/S guided nerve block of the wrist. It worked well, decreased pain, took only 7-10 minutes to perform.


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