Monday, May 28, 2007

May Abstracts

  • Marcus, G.M., et al, Am J Med 120(1):83, January 2007: Utility of "gestures" in patients with chest pain. Levine's sign- grasping of the chest is the classic example. They looked at four different gestures patients would use to describe their chest pain. Few patients made a sign but not a reliable indicator. Very poor sensitivity, reasonable specificity, but not much help.
  • Ramsay, G., et al, Quart J Med 100(1):11, January 2007: Risk prediction of patients presenting w/ CP. They compared TIMI scores w/ clinical impression. The problem is even low TIMI scores still end up w/ a 5% MI rate. Not a great study.
  • Emery, M., et al, Am Heart J 152(6):1015, December 2006: B-blockers in NSTEMI- patients discharged randomized to being on beta-blocker or not. Of course the sicker patients often don't get B-blockers (hypotensive, brady, etc). Prior studies (COMMIT) trial show that B-blockers may induce cardiogenic shock due to decreased CO, but fewer arrhythmias. Bottom line is B-blockers have some benefit, but can cause deleterious effects.
  • Sampson, F.C., et al, Eur Radiol 17(1):175, January 2007: MRI for DVT- meta-analysis comparing U/S vs. MRI; quite a few heterogeneous studies and MRI is not better than U/S. While U/S has some flaws, still our best initial test.
  • Blomkalns, A.L., et al, Am Heart J 152:1182, December 2006: Testing cholesterol in ED patients at risk for ACS. Sponsored by Merck. They did a 6 hour fasting cholesterol level (right....). People who had elevated levels often didn't follow-up or get put on meds. Seems like a push by a drug company to get more docs to prescribe their meds. If they have ACS, they should be on a statin (regardless of the cholesterol level- so why test?).
  • Jones, K., et al, Am J Surg 192:743, 2006: A small study looking at CHI patients already on plavix (N= 40). No methods listed in this chart review. 36% brain bleeds on pts on plavix; 48% in the control group. Can't really gleam anything based on the small number and intuition already would lead you to believe people are at risk for bleeding.
  • Miner, J.R., et al, Am J Emerg Med 25:60, 2007: Imitrex SQ wasn't that effective in migraine and tension H/A's. Only a modest decrease in pain scale. More than half had a response, but not a big response. Of course these may be patients who have already failed outpt Imitrex and therefore you have a select subgroup.
  • Nigrovic, L.E., et al, JAMA 297(1):52, January 3, 2007: Chart review of pediatrics w/ meningitis. Vast majority was viral in origin. 98% of patients w/ bacterial meningitis had one of these criteria- + CSF gram stain, more than 1000 absolute neutrophils, high protein count, high peripheral WBC (not very helpful to me). Bottom line, is quite a few who might be bacterial end up being viral after cultures grow out. If you're going to error, error on the side of over-treating. Wait for the cultures, etc.
  • Shah, K., et al, J Emerg Med 32(1):15, January 2007: Elderly patients with CSF sent due to AMS. Some afebrile patients ended up w/ meningitis. Bottom line, is lack of fever doesn't exclude meningitis in elderly patients w/ AMS. However, low yield.
  • Savitz, S.I., et al, Acad Emerg Med 14(1):63, January 2007: Cerebellar infarction comprise 2-3% of ischemic CVA's. Retrospective review of 15 cases originally misdiagnosed. Seven of the patients were less than 50 yo. Some had a H/A, some w/ dizziness, some w/ N/V. Bottom line is you have to keep it in the back of your mind on patients w/ some of these sx's. I remember one patient I had who came in w/ acute N/V, dizziness. Negative head CT, but just didn't look right. MRI in the ED showed a large cerebellar CVA. If it's acute onset, characteristics of "central" vertigo, etc. consider the MRI even w/ a normal CT.
  • Bull, S.V., et al, Crit Care Med 35(1):41, January 2007: Standard protocol in adults w/ DKA. They don't tell you what the protocol is however (a little strange). When they used the "protocol" they had shorter ICU stays, shorter hospital stays, etc. I'm sure soon enough we'll be using a standard DKA protocol (akin to the sepsis protocol).
  • Chen, E.H., e al, Ann Emerg Med 49(1):64, January 2007: Household electrical exposures in children- if you didn't have an arrhythmia in the field and no symptoms in the ED, the patient did fine. You don't need an EKG or admission if they didn't have water contact or symptoms in low voltage exposures.
  • Patel, P.B., et al, Acad Emerg Med 14(1):1, January 2007: Bacterial conjunctivitis in children- 78% had positive cultures - most were H. influenzae non-typable. Does it matter since you're going to trx all cases w/ Abx anyways? Also except for gonococcal, they're going to get better anyways.
  • Aguilar, M.I., et al, Mayo Clin Proc 82(1):82, January 2007: Treatment of Coumadin-associated ICH. They used 7 "experts" who are the authors. They recommend urgently correcting anticoagulation in these patients. What about a small, asymptomatic SDH? They recommend factor 7 (the expensive stuff). They say Vit K takes too long and FFP can lead to "fluid overload". The "experts" also work for the company that creates the recommended therapy (amazing how that works...).
  • Li, S.F., et al, Emerg Med J 24:75, February 2007: Children w/ arthrocentesis - peripheral WBC and ESR were useless to predict septic arthritis. Joint fluid WBC was moderate but not great. 17,500 was their cut-off, but still not great sensitivity or specificity. Bottom line, is if you're concerned about it, just treat while you're waiting for the culture since the markers aren't reliable predictors.
  • Shah, K., et al, J Emerg Med 32(1):23, January 2007: Does the presence of crystal arthritis r/o septic arthritis? Retrospective look at patients w/ crystals in their synovial fluid (gout or pseudogout). 4% had positive cultures. If you have greater than 50,000 WBC, then you might as well treat for a septic joint as well.
  • Sharma, O.P., et al, Am Surg 73:70, January 2007: If you have one cervical spine fx, look for other fractures. 26% were non-contiguous injuries. Image the entire spine.
  • Al-Ansari, K., et al, Can J Emerg Med 9(1):9, January 2007: Peds patients w/ radius fx w/ less than 15% angulation and less than 0.5 cm step-off. They all did well whether they placed them in a short cast, long-arm cast or kept them in the splint.
  • Grijalva, C.G., et al, Pediatrics 119(1):e6, January 2007: Rapid flu tests in children- during the height of the flu season, your clinical judgment is effective. Poor positive predictive value.
  • Bossart, P., et al, J Emerg Med 32(1):19, January 2007: No change in visual pain score and heart rate. Of course that's assuming the pain scale is valid in the first place. They also didn't make a big change on the pain scale suggesting they didn't even treat their pain much.
  • Baumann, B.M., et al, Acad Emerg Med 14(1):47, January 2007: By using pain templates, you document pain scales better, but don't end up treating or resolving it any better.
  • Arora, S., et al, Can J Emerg Med 9(1):30, January 2007: Comparing Toradol 60 mg IM vs ibuprofen. It takes 45 minutes to get appropriate blood levels of toradol IM. IV blood levels are in 5 minutes. If you're going to give Toradol IM- just give them Ibuprofen PO. It works as quickly and pain control is similar. Plus it's a lot more expensive.
  • Colebourn, C.L., et al, Anaesthesia 62(1):34, January 2007: Heliox in asthma and COPD- meta-analysis but no benefit of Heliox in these patients.
  • Beers, S.L., et al, Am J Emerg Med 25(1):6, January 2007: BiPAP in pediatrics w/ status asthmaticus. Chart review w/ no methods listed. Refractory to conventional therapy. Average duration was 6 hours and seemed to help (using continuous albuterol). Perhaps it wasn't the Bi-Pap but the continuous SVN's. Poorly constructed study.
  • Salhi, B., et al, Ann Emerg Med 4(1):84, January 2007: Use of lidocaine w/ RSI- two studies (each took a different position). The thought is it helps blunt the rise in ICP. But does it cause a clinical significance? Also lidocaine might decrease CO and it takes a couple minutes to work, so can you wait? Probably in the grand scheme of things, if you can give it quickly, fine. But I wouldn't delay care waiting for it.
  • Svenson, J.E., et al, Am J Emerg Med 25:53, January 2007: ETT intracuff pressures in the ED- concern is tracheal mucosa ischemia if it's overinflated. One animal study showed that if you exceed capillary perfusion pressure for greater than 15 minutes, you can do damage. The average mean pressure was 62 (high). For the most part, we overinflate. Squeezing the little balloon doesn't reliably serve as an indicator.

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