PEMS

September EMA Abstract Review

2007-10-07T17:39:00.000-07:00

1. USEFULNESS OF 64-SLICE MULTIDETECTOR COMPUTED TOMOGRAPHY IN DIAGNOSTIC TRIAGE OF PATIENTS WITH CHEST PAIN AND NEGATIVE OR NONDIAGNOSTIC EXERCISE TREADMILL TEST RESULT. Rubinshtein, R., et al, Am J Card 99(7):925, April 1, 2007: 100 patients after neg or non-dx exercise treadmill had CTA with a PPV of 90% (all positives had a cath) and a NPV of 93% (but only those with persistent issues had a cath). More limited, wishy-washy evidence that CTA may be helpful.
2. USEFULNESS OF 64-SLICE CARDIAC COMPUTED TOMOGRAPHIC ANGIOGRAPHY FOR DIAGNOSING ACUTE CORONARY SYNDROMES AND PREDICTING CLINICAL OUTCOME IN EMERGENCY DEPARTMENT PATIENTS WITH CHEST PAIN OF UNCERTAIN ORIGIN. Rubinshtein, R., et al, Circulation 115:1762, April 3, 2007: Similar study, with intermediate risk patients. Only 52% PPV and 97% NPV in this study. See above.
3.A PRACTICAL APPROACH WITH OUTCOME FOR THE PROGNOSTIC ASSESSMENT OF NON-ST-SEGMENT ELEVATION CHEST PAIN AND NORMAL TROPONIN. Sanchis, J., et al, Am J Card 99(6):797, March 15, 2007: Combined previously published risk strat model (One point each was assigned for four of the items ("typical" chest pain presentation, two or more episodes in the previous 24 hours, age 67 years or older, previous PTCA) and two points were assigned if the patient had insulin-dependent diabetes.) with presence of ST-depression or Trop elevation. No surprise that the lowest risk group had lower outcome measures than other groups, but still had a 9% event rate by 15 months.
4. COLD INFUSIONS ALONE ARE EFFECTIVE FOR INDUCTION OF THERAPEUTIC HYPOTHERMIA BUT DO NOT KEEP PATIENTS COOL AFTER CARDIAC ARREST. Kliegel, A., et al, Resuscitation 73(1):46, April 2007: Infusion of cold fluids can get patients to target temp (32-34 C) but could not maintain it without adjunctive cooling measures. We will be seeing a lot of these studies looking at how to keep the post-dead patients cold. How’s about not wasting resources on dead patients in the first place? Sorry, sarcasm got away from me there.
5. IMPLEMENTATION OF A STANDARDISED TREATMENT PROTOCOL FOR POST RESUSCITATION CARE AFTER OUT-OF-HOSPITAL CARDIAC ARREST. Sunde, K., et al, Resuscitation 73(1):29, April 2007: Multifaceted goal directed approach (sound familiar?) to post-resuscitation care (therapeutic hypothermia and PCI when appropriate) as well as therapies to maintain blood pressure and heart rate targets, ventilation goals, blood sugar, electrolyte and hemoglobin values, diuresis and seizure control) improved survival to neurologically good hospital discharge (56% v. 26%). I can see this coming down the road, and will need to be started in the ED. Can’t you just see a ‘Surviving Death’ campaign?
6. MAJOR HEMORRHAGE AND TOLERABILITY OF WARFARIN IN THE FIRST YEAR OF THERAPY AMONG ELDERLY PATIENTS WITH ATRIAL FIBRILLATION. Hylek, E.M., et al, Circulation 115:2689, May 29, 2007: 5% of patients bleed in the first year of starting warfarin. Many stop the drug due to complications. Those at highest risk for CVA are also the ones at risk for complications and for stopping the drug.
7. PROACTIVE ADMINISTRATION OF PLATELETS AND PLASMA FOR PATIENTS WITH A RUPTURED ABDOMINAL AORTIC ANEURYSM: EVALUATING A CHANGE IN TRANSFUSION PRACTICE. Johansson, P.I., et al, Transfusion 47:593, April 2007: These researchers transfused platelets, pRBC’s and FFP as soon as the diagnosis was made and again before unclamping the aorta in the OR. 50% survival increase (44% without protocol and 66% with protocol). Increasing BP and blood volume leading to increasing uncontrolled bleeding need to be considered as well. Needs to be reproduced to start to use.
8. WHAT VASOPRESSORS SHOULD BE USED TO TREAT SHOCK. Jones, A.E., Ann Emerg Med 49(3):367, March 2007: Review of 7 studies looking mainly at septic shock show trivial hemodynamic improvement with norepi and dobut v. epi, and potentially worse outcome with vasopressin v. placebo. No clear answers here and the existing evidence sucks. Don’t believe the BS when someone berates you for using the ‘wrong’ pressor.
9. EXTERNAL VALIDATION OF THE SAN FRANCISCO SYNCOPE RULE IN THE AUSTRALIAN CONTEXT. Cosgriff, T.M., et al, Can J Emerg Med 9(3):157, May 2007: Yet another look at the SFSR. This one from Oz showed higher admission and equal outcome when comparing SFSR to clinician judgment. That’s right: The SFSR did worse!
10. DEPRESSION AND COST-RELATED MEDICATION NONADHERENCE IN MEDICARE BENEFICIARIES. Bambauer, K.Z., et al, Arch Gen Psych 64:602, May 2007: Large survey of medicare recipients showing that all are at risk for not taking meds because of cost, but that those who were depressed were even more likely to have this issue. Ask your patients if they are taking their meds, and if not, is it because of financial reasons. Financial counselors may be able to help. Switch to generics, etc…
11. SECONDARY PREVENTION OF STROKE AND TRANSIENT ISCHEMIC ATTACK: IS MORE PLATELET INHIBITION THE ANSWER? Liao, J.K., Circulation 115:1615, March 27, 2007: Review of available studies. Benefit of extended-release dipyramidole plus aspirin as opposed to asa alone: 1 less CVA per 100-person-years. Risk v. benefits need to be discussed in choosing therapy for prophylaxis in this population.
12. COST-EFFECTIVENESS OF ECHOCARDIOGRAPHY TO IDENTIFY INTRACARDIAC THROMBUS AMONG PATIENTS WITH FIRST STROKE OR TRANSIENT ISCHEMIC ATTACK. Meenan, R.T., et al, Med Dec Making 27:161, March-April 2007: Always questionable cost-effective analysis suggests TTE or TEE is unlikely to be cost-effective for first stroke or TIA unless patient is at high risk (i.e. prior cardiac disease). I suspect the hospitalists will continue to want this on the TIA/CVA patients we admit, however.
13. PATIENTS DEROGATE PHYSICIANS WHO USE A COMPUTER-ASSISTED DIAGNOSTIC AID. Arkes, H.R., et al, Med Dec Making 27:189, March-April 2007: Using an electronic decision aid during a patient encounter decreased patient satisfaction in this interesting study. Leave the Palm in the pocket, look at it outside the room, and explain why you are doing or not doing a test/procedure without dragging in the decision aid.
14. THE EFFECT OF EMERGENCY DEPARTMENT EXPANSION ON EMERGENCY DEPARTMENT OVERCROWDING. Han, J.H., et al, Acad Emerg Med 14(4):338, April 2007: Fascinating study (for a geek like me) looking at an ED that expanded from 28 to 53 beds. No change in ambulance diversion and an increase in ED LOS. It indicates that efficiency is a multifactorial problem, not isolated to having limited space in which to work. Bottom line: It’s not how big your ED is, it’s how you use it.15. PHYSICIAN CONSIDERATION OF PATIENTS' OUT-OF-POCKET COSTS IN MAKING COMMON CLINICAL DECISIONS. Pham, H.H., et al, Arch Intern Med 167:663, April 9, 2007: Physicians consider patient costs when prescribing drugs, but not so much when ordering tests or admitting patients. It is very difficult to discuss these issues in the ED, where we have little knowledge of costs and insurance coverage, and where we do what we think is necessary. But 90% of medical costs flow from the physician’s pen. Think about what you write.
16. VALACYCLOVIR AND PREDNISOLONE TREATMENT FOR BELL'S PALSY: A MULTICENTER, RANDOMIZED, PLACEBO-CONTROLLED STUDY. Hato, N., et al, Otol Neurotol 28(3):408, April 2007: Perisistent question: Do antivirals help Bell’s? In this Japanese study, those with severe or total paralysis may have benefit if valtrex is started early. I will continue to prescribe it for my Bell’s patients who present early.
17. CARDIAC MONITORING OF HIGH-RISK PATIENTS AFTER AN ELECTRICAL INJURY: A PROSPECTIVE MULTICENTRE STUDY. Bailey, B., et al, Emerg Med J 24:348, May 2007: 134 patients with high-risk electrical injuries with no arrhythmia at baseline monitored for 24-hours showed no delayed arrhythmias. CI’s wide, but pretty good evidence here.
18. INTRAVENOUS DEXTROSE DURING OUTPATIENT REHYDRATION IN PEDIATRIC GASTROENTERITIS. Levy, J.A., et al, Acad Emerg Med 14(4):324, April 2007: Treatment with glucose containing IV fluids decreased return revisit rate (OR 1.9), but treatment with antiemetics had a bigger effect (OR 4.4). TAKE HOME POINT: If using IV to rehydrate these tykes, use dextrose containing fluids.
19. LOPERAMIDE THERAPY FOR ACUTE DIARRHEA IN CHILDREN: SYSTEMATIC REVIEW AND META-ANALYSIS. Li, S.T.T., et al, PLoS Med 4(3):e98, March 2007: Use of loperamide was helpful for children with diarrhea who were not really sick (no bloody diarrhea, no severe dehydration), but increase risk (lethargy, ileus, even death) for those younger than 3.
20. EARLY ANTIBIOTIC TREATMENT FOR SEVERE ACUTE NECROTIZING PANCREATITIS. Dellinger, E.P., et al, Ann Surg 245(5):674, May 2007: Sponsored study by the makers of meropenem on using it prophylactically with necrotizing pancreatitis patients without evidence of pancreatic infection at study onset showed no benefit in any outcome measure. Bottom line: Do not use meropenem just to use it.
21. COST-EFFECTIVE DIAGNOSIS OF INGESTED FOREIGN BODIES. Shrime, M.G., et al, Laryngoscope 117:785, May 2007: Based on the authors’ assumptions, CT should be considered the first test for fb sensation in the throat in adults. They failed to account for differences between glass/metal versus radiolucent fb’s, which I think make the conclusions of this study almost useless. My personal opinion: You may want to consider CT first if the object is felt to be radiolucent (i.e. meat) but for our glass and metal eaters out there, I would still go for xray first. Or if you really think it’s there, send them straight to laryngoscopy.
22. CASE-SERIES OF NURSE-ADMINISTERED NITROUS OXIDE FOR URINARY CATHETERIZATION IN CHILDREN. Zier, J.L., et al, Anesth Analg 104(4):876, April 2007: Nice study of 1018 kids getting urinary caths given laughing gas by nurses trained to use and monitor it. It worked, with low adverse event rate (4%), 1% failure rate and 1% over-sedation rate, with no serious adverse events. This is really cool, but it is hard enough for the docs to get NO2 approved, let alone nurses.
23. THE RENO-PROTECTIVE EFFECT OF HYDRATION WITH SODIUM BICARBONATE PLUS N-ACETYLCYSTEINE IN PATIENTS UNDERGOING EMERGENCY PERCUTANEOUS CORONARY INTERVENTION: THE RENO STUDY. Recio-Mayoral, A., et al, J Am Coll Cardiol 49(12):1283, March 27, 2007: IV NAC and bicarb decreased the risk of CIN in high risk patients (Most CIN is a lab diagnosis only, but occasionally real events occur: anuric renal failure in 1 in placebo and 7 in control group). Another study looking at NAC for preventing CIN, this one with more positive results than others. The jury is still out.
24. UPDATE ON EMERGING INFECTIONS FROM THE CENTERS FOR DISEASE CONTROL AND PREVENTION: REVISED RECOMMENDATIONS FOR HIV TESTING OF ADULTS, ADOLESCENTS AND PREGNANT WOMEN IN HEALTH-CARE SETTINGS. Rothman, R.E., et al, Ann Emerg Med 49(5):575, May 2007: The CDC now recommends all patients btw 13 and 64 get screened (with their consent) for HIV in all healthcare settings. This would include the ED. This is clearly not the appropriate place to screen for most patients, with a decided lack of follow-up and counseling available. It may be reasonable in some situations (rape, evidence of opportunistic infection in at-risk patient, STD’s), but not everyone.
25. SEVERE DENGUE VIRUS INFECTION IN TRAVELERS: RISK FACTORS AND LABORATORY INDICATORS. Wichmann, O., et al, J Infect Dis 195:1089, April 15, 2007: Common and increasingly prevalent infection, seen more in the US due to more frequent travel to endemic regions (almost anywhere warm and moist). Although most infections are minor or even sub-clinical, some develop anemia, thrombocytopenia, elevated LFTs. Dengue hemorrhagic fever, although rare is potentially fatal. Supportive care is indicated. Also called colloquially ‘breakbone fever.’ Confirmatory testing takes too long for the ED.
26. IMPLEMENTING AN HIV AND SEXUALLY TRANSMITTED DISEASE SCREENING PROGRAM IN AN EMERGENCY DEPARTMENT. Silva, A., et al, Ann Emerg Med 49(5):564, May 2007: Here is a hospital (Sinai in Chicago) that implemented a program as described in 24. In this higher risk than general US population set, HIV was id’ed in 8 patients, but they were only able to hook up 3 w/ care. Again, I feel the ED is not the appropriate location to do screening due to follow-up and counseling limitations.
27. ALARM SYMPTOMS IN EARLY DIAGNOSIS OF CANCER IN PRIMARY CARE: COHORT STUDY USING GENERAL PRACTICE RESEARCH DATABASE. Jones, R., et al, Br Med J 334:1040, May 2007: Review of extensive FP records in UK showed that the first episode of hematuria, rectal bleeding, hemoptysis or dysphagia increased the risk of finding a related cancer by 100-fold. Suggest that CA screening be initiated if any one of these findings occur, particularly in older male patients. Lesson for ED: Strongly suggest follow-up for any of these episodes if not otherwise well explained (i.e. kidney stone).
28. COMPARISON OF ORAL PREDNISOLONE-PARACETAMOL AND ORAL INDOMETHACIN- PARACETAMOL COMBINATION THERAPY IN THE TREATMENT OF ACUTE GOUTLIKE ARTHRITIS. Man, C.Y., et al, Ann Emerg Med 49(5):670, May 2007: Traditional treatment of gout includes indomethacin. This study showed prednisolone was as effective as indocin with fewer side effects. TAKE HOME POINT: Steroids for gout should be something to consider, particularly if the patient cannot take NSAIDs.
29. NECK COLLAR, "ACT-AS-USUAL" OR ACTIVE MOBILIZATION FOR WHIPLASH INJURY? Kongsted, A., et al, Spine 32(6):618, March 15, 2007: Whiny patients at ‘high-risk’ for continued pain (whiplash associated disorder) randomized to above treatment groups with no significant differences found between groups at 1 year, but a surprising number with perisistent symptoms (~25% with interference with job and >50% still using analgesics). This study is from Holland, and we thought all the wimps were in the US.
30. USE OF SELECTED CEPHALOSPORINS IN PENICILLIN-ALLERGIC PATIENTS: A PARADIGM SHIFT. Pichichero, M.E., Diagn Microbiol Infect Dis 57(3):13S, March 2007: Due to multiple factors, early studies concluded higher risk of cross-reactivity between pcn-allergic patients given cephalosporins. More recent studies suggest much less risk, particularly with later generation cephalosporins. Take Home Point: It is almost always ok to use 2nd or higher gen cephalosporins in patients with PCN allergy history.
31. RECALL AFTER PROCEDURAL SEDATION IN THE EMERGENCY DEPARTMENT. Swann, A., et al, Emerg Med J 24:322, May 2007: Less than 5% of patients could recall the sedation and procedure in follow-up phone-calls. Sedation agents used were not standardized, but study too small to make specific drug recommendations. Lesson to be learned: Sedation – oh, never mind. I can’t remember.
32. EVIDENCE-BASED REVIEW OF THE BLACK-BOX WARNING FOR DROPERIDOL. Jackson, C.W., et al, Am J Health Syst Pharm 64:1174, June 1, 2007: Structured eval of reports that led to black box warning. Almost all were either felt to be not related to droperidol, or were related to doses 50 to 100 times higher than typically used in the ED for N/V or acute psychosis. There are hints at nefarious drug company-FDA collusion, as this warning comes decades after droperidol first came on the market, but only a few years after zofran was approved.
33. EVALUATION OF THE UTILITY OF RADIOGRAPHY IN ACUTE BRONCHIOLITIS. Schuh, S., et al, J Ped 150:429, April 2007: Use of xrays increased treatment with antibiotics, but most use of abx was felt to be not indicated by the authors in this study. <1% of patients had a real change of management based on xray. Take Home: If it looks like bronchiolitis, skip the film.
34. IDENTIFICATION OF 90% OF PATIENTS ULTIMATELY DIAGNOSED WITH COMMUNITY-ACQUIRED PNEUMONIA WITHIN FOUR HOURS OF EMERGENCY DEPARTMENT ARRIVAL MAY NOT BE FEASIBLE. Fee, C., et al, Ann Emerg Med 49(5):553, May 2007: A third of the patients in this UCSF study did not get their abx within 4 hours, and many of those did not have an ED diagnosis of CAP. They suggest that it would be impossible to meet the 90% goal. The goal has shifted somewhat, so that we only have to make it on those diagnosed in the ED, but the documentation must support that.
35. UTILIZATION OF ARTERIAL BLOOD GAS MEASUREMENTS IN A LARGE TERTIARY CARE HOSPITAL. Melanson, S.E.F., et al, Am J Clin Path 127(4):604, April 2007: Hospital wide review at the mecca (Brigham and Women’s) found that 30% of ABG’s were probably not necessary. I suspect they were being generous. ED Lesson: Order the ABG only if you are going to do something with the results.
36. ATROPINE: RE-EVALUATING ITS USE DURING PAEDIATRIC RSI. Bean, A., Emerg Med J 214:361, May 2007: Very little evidence found by these authors. The one good study showed no difference in episodes of bradycardia with or without atropine for RSI. Authors suggest that adding atropine to pediatric RSI may not be necessary.
37. ADVANCED LIFE SUPPORT FOR OUT-OF-HOSPITAL RESPIRATORY DISTRESS. Stiell, I.G., et al, N Engl J Med 356(21):2156, May 24, 2007: There was a 1.9% absolute decrease in mortality after initiation of a large pre-hospital ACLS program, even though only 1.4% of patients got tubed in the field, and other ACLS interventions were also used on a limited basis. This is one of the few studies (and a well done one) that showed any benefit to pre-hospital advanced interventions.
38. THE EVIDENCE BASE FOR CEPHALOSPORIN SUPERIORITY OVER PENICILLIN IN STREPTOCOCCAL PHARYNGITIS. Casey, J.R., et al, Diagn Microbiol Infect Dis 57(3):39S, March 2007: Meta-analysis suggests cephalosporins should be first line for strep throat, due to increasing resistance to pcn. Not sure if I am ready to make the switch. Any thoughts from P&T on the strep antimicrobial spectra in our neck of the woods?
39. THE ROLE OF ANTIBIOTIC PROPHYLAXIS FOR PREVENTION OF INFECTION IN PATIENTS WITH SIMPLE HAND LACERATIONS. Zehtabchi, S., Ann Emerg Med 49(5):682, May 2007: Like last months study, there is no convincing evidence to use prophylactic antibiotics in simple hand lacerations. Does anyone actually do this anymore? I hope not.
40. A MULTICENTER COMPARISON OF TAP WATER VERSUS STERILE SALINE FOR WOUND IRRIGATION. Moscati, R.M., et al, Acad Emerg Med 14(5):404, May 2007: Once again, tap water irrigation is safe, effective and cheaper than using sterile saline. I think this is very useful, especially for hand and forearm wounds where I often have patients clean their own wounds.

August 2007 EMA Abstract Review

2007-09-21T11:19:00.000-07:00

1. BENEFITS OF ROUTINE USE OF CORONAL AND SAGITTAL REFORMATIONS IN MULTI-SLICE CT EXAMINATION OF THE ABDOMEN AND PELVIS, Sandrasegaran, K., et al, Clin Rad 62(4):340, April 2007 : The authors feel that they get more info when the CT images are reformatted in multiple planes, and suggest this should be routine. Will not change our practice (we already do this with stone ct’s).
2. EXTERNAL VALIDITY OF ST ELEVATION MYOCARDIAL INFARCTION TRIALS: THE ZWOLLE STUDIES, Rasoul, S., et al, Cath Cardiovasc Interventions 69(5):632, April 1, 2007 : Patients who are older, sicker and female are less likely to be enrolled in clinical trials and registries, even if they meet criteria. They are more likely to die, and less likely to get standard of care. Another study (this one Dutch) indicating significant bias where we think there isn’t any.
3. DOES THIS PATIENT WITH A PERICARDIAL EFFUSION HAVE CARDIAC TAMPONADE?, Roy, C.L., et al, JAMA 297(16):1810, April 25, 2007 : No clinical findings are sufficient to rule out tamponade. TAKE HOME POINT: ECHO is required if tamponade is a consideration.
4. FREQUENCY OF AND INAPPROPRIATE TREATMENT OF MISDIAGNOSIS OF ACUTE AORTIC DISSECTION, Hansen, M.S., et al, Am J Card 99(6):852, March 15, 2007 : 39% of patients were initially misdiagnosed, (usually as ACS, most with ST changes or marker elevation) and were more likely to die or bleed. Despite frequent reminders to consider TAD, we still miss it 4 out of 10 times. Keep a high index of suspicion, yada yada…
5. RECOGNIZING ASYMPTOMATIC ELEVATED BLOOD PRESSURE IN ED PATIENTS: HOW GOOD (BAD) ARE WE?, Tilman, K., et al, Am J Emerg Med 25(3):313, March 2007 : Only 7% of patients w/ new onset asymptomatic elevated BP had this addressed during the ED visit. Appropriate management might be just to put it on the dc instructions and encourage patients to get it followed up.
6. EXTERNAL VALIDATION OF THE SAN FRANCISCO SYNCOPE RULE, Sun, B.C., et al, Ann Emerg Med 49(4):420, April 2007 : Validation study for the SFSR showed lower sensitivity and specificity (89%/42%) than the derivation study. I’m not willing to risk an 11% adverse event rate upon discharge from the ED. I will continue to admit most syncope’s I can’t otherwise clearly explain.
7. PREDICTING INTRACRANIAL TRAUMATIC FINDINGS ON COMPUTED TOMOGRAPHY IN PATIENTS WITH MINOR HEAD INJURY: THE CHIP PREDICTION RULE, Smits, M., et al, Ann Intern Med 146(6):397, March 20, 2007 : Complex rule (read: You are not going to be able to use this rule) found all patients requiring neurosurgery, but missed 5% with abnormal CT findings and only reduced CT use only moderately. No.
8. EVALUATION OF A MODIFIED PREDICTION INSTRUMENT TO IDENTIFY SIGNIFICANT PEDIATRIC INTRACRANIAL INJURY AFTER BLUNT HEAD TRAUMA, Sun, B.C., et al, Ann Emerg Med 49(3):325, March 2007 : Attempt at external validation of a 5 part rule (altered mental status, evidence of skull fx, scalp hematoma (if <2yo), vomiting and headache) with the pediatric group of the NEXUS 2 data set. Sensitivity of 90.4% would have missed 13 patients with ICI. Not ready for prime time.
9. SUMATRIPTAN-NAPROXEN FOR ACUTE TREATMENT OF MIGRAINE, Brandes, J.L., et al, JAMA 297(13):1443, April 4, 2007: Worked better than sumatriptan alone, but as it didn’t include wooly mammoth doses of narcotics, there were frequent treatment failures and recurrences. You might want to try this from Yellow Pod, but by the time they make it to us, they often require more.
10. MISSED DIAGNOSIS OF SUBARACHNOID HEMORRHAGE IN THE EMERGENCY DEPARTMENT, Vermeulen, M.J., et al, Stroke 38:1216, April 2007 : Multicenter study showed a 5% initial miss rate (lower than previously published). More likely to not look sick, and more likely to show up at a non-teaching hospital. Interestingly, mortality was much lower in these missed patients (6.2 v 33.9%). Keep a high index of suspicion, yada, yada…
11. THE OPPORTUNITY LOSS OF BOARDING ADMITTED PATIENTS IN THE EMERGENCY DEPARTMENT, Falvo, T., et al, Acad Emerg Med 14(4):332, April 2007 : In a 62,000 visit ED, this study estimated a $4 million annual loss for the hospital ($1M of which was professional fees) due to patients that could have been seen but were not due to boarding inpatients in the ED. Boarding: Bad for patients, bad for business.
12. ACUTE OTITIS MEDIA AND RESPIRATORY VIRUSES, Bulut, Y., et al, Eur J Ped 166(3):223, March 2007 : 54% of middle ear cultures grew bacteria, 33% viruses, and the rest were unidentified. It’s a coin toss if it’s bacterial. Does this mean go back to treating all OM with abx? Let’s wait and see…
13. JUDICIOUS ANTIBIOTIC USE AND INTRANASAL CORTICOSTEROIDS IN ACUTE RHINOSINUSITIS, Small, C.B., et al, Am J Med 120(4):289, April 2007 : Review article. Only 38% of acute sinusitis is bacterial. May improve with antihistamines, nasal steroids, decongestants alone. Suggest wait-and-see abx if symptoms persist or worsen in 5-7 days, or for high risk patients (unilateral tenderness, facial or dental pain, mucopurulent drainage).
14. OMEPRAZOLE BEFORE ENDOSCOPY IN PATIENTS WITH GASTROINTESTINAL BLEEDING, Lau, J.Y., et al, N Engl J Med 356(16):1631, April 19, 2007 : H1 blocker prior showed improved surrogate findings at endoscopy, but did not change real outcomes (units transfused, need for surgery, death). I will continue to use them on the bleeding ulcer patients in the ED until someone tells me it makes them worse.
15. A COMPARATIVE STUDY ON BACTERIAL CULTURES OF URINE SAMPLES OBTAINED BY CLEAN-VOID TECHNIQUE VERSUS URETHRAL CATHETERIZATION, Lau, A.Y., et al, Acta Paed 96(3):432, March 2007 : Hong Kong study: Suprapubic aspiration suggested for uncircumcised boys, and cath for girls below age 2 to minimize false positive cultures. No recs for circumcised boys (what’s a Jew to do?), as all males in this study were uncircumcised.
16. DISCORDANCE BETWEEN SERUM CREATININE AND CREATININE CLEARANCE FOR IDENTIFICATION OF ED PATIENTS WITH ABDOMINAL PAIN AT RISK FOR CONTRAST-INDUCED NEPHROPATHY, Band, R.A., et al, Am J Emerg Med 25(3):268, March 2007 : We use serum creatinine (in this study a 1.5mg/dl cut-off) as a surrogate marker of low creatinine clearance (<60ml/min). It is a low clearance that increases risk for contrast induced nephropathy. This study showed that 40% of those with low clearance had a serum creatinine < 1.5. Although they suggest calculating clearance on all patients getting a contrast study. One commonly used formula: (140-age)*wt in kg/([Cr]*72) for males, with a 0.85 correction factor for females. I will not be doing this any time soon.
17. IMPACT OF AN EMERGENCY DEPARTMENT PAIN MANAGEMENT PROTOCOL ON THE PATTERN OF VISITS BY PATIENTS WITH SICKLE CELL DISEASE, Givens, M., et al, J Emerg Med 32(3):239, April 2007 : Discontinuing use of Demerol, discharging with a handful of hydrocodone and referring all to hematology clinic shifted sicklers out of ED and into the hematology clinic. This is good stuff. Now if we could only do this with migraines and back pain…
18. EMERGENCY DEPARTMENT MANAGEMENT OF ACUTE PAIN EPISODES IN SICKLE CELL DISEASE, Tanabe, P., et al, Acad Emerg Med 14(5):419, May 2007 : The American Pain Society recommends 0.1 to 0.15mg/kg of morphine or 0.015 to 0.02mg/kg of dilaudid within 15 minutes of arrival for SS pain crises. The hospitals studied did not do that well with this, often treating other patients with less reported pain prior to the sicklers. Bottom line: Treat their pain aggressively, skip the Demerol.
19. ORAL RIFAMPIN FOR ERADICATION OF STAPHYLOCOCCUS AUREUS CARRIAGE FROM HEALTHY AND SICK POPULATIONS: A SYSTEMATIC REVIEW OF THE EVIDENCE FROM COMPARATIVE TRIALS, Falagas, M.E., et al, Am J Infect Control 35:106, March 2007 : Use of rifampin reduced risk of infection in asymptomatic carriers at the risk of 17% developed rifampin-resistant SA.
20. IMPLEMENTATION OF A BUNDLE OF QUALITY INDICATORS FOR THE EARLY MANAGEMENT OF SEVERE SEPSIS AND SEPTIC SHOCK THAT IS ASSOCIATED WITH DECREASED MORTALITY, Nguyen, H.B., et al, Crit Care Med 35(4):1105, April 2007 : Early goal-directed therapy takes work and time, but consistently saves lives in multiple studies, including this one. TAKE HOME POINT: Follow the sepsis protocol!!!
21. COST EFFECTIVENESS OF PERTUSSIS VACCINATION IN ADULTS, Lee, G.M., et al, Am J Prev Med 32(3):186, March 2007 : Using dTaP either as a mass-immunization plan or every 10-years is cost effective at the current incidence of pertussis (360 cases per 100,000 population). Another push towards dTaP and away for Td.
22. LITIGATION OF MISSED CERVICAL SPINE INJURIES IN PATIENTS PRESENTING WITH BLUNT TRAUMATIC INJURY, Lekovic, G.P., et al, Neurosurgery 60(3):516, March 2007: BNI study of 20 closed cases, with 8 for defendant (yea!) and 12 for plaintiff (boo!), with an average settlement of $2.9M per case. Most cases were an error in reading a study.
23. TRAMADOL/ACETAMINOPHEN OR HYDROCODONE/ACETAMINOPHEN FOR THE TREATMENT OF ANKLE SPRAIN: A RANDOMIZED, PLACEBO-CONTROLLED TRIAL, Hewitt, D.J., et al, Ann Emerg Med 49(4):468, April 2007 : Essentially equivalent pain relief with ultraset or vicodin and better than placebo (go figure). No reason to go for the more expensive new toy on the block.
24. SINGLE FASCIA ILIACA COMPARTMENT BLOCK FOR POST-HIP FRACTURE PAIN RELIEF, Monzon, D.G., et al, J Emerg Med 32(3):257, April 2007 : The procedure consisted of injection of 0.3ml/kg of 0.25% bupivacaine into the lumbar plexus at the juncture of the medial and lateral thirds of a line connecting the pubic symphysis and the anterior superior iliac spine. Results in significantly diminished pain and lower need for other meds. It’s worth a shot (get it, worth a shot!).
25. THORACIC INTERVERTEBRAL DISK HERNIATION: A COMMONLY MISSED DIAGNOSIS, Linscott, M.S., et al, J Emerg Med 32(3):235, April 2007 : Rare and frequently missed cause of back pain, often with radiation to buttocks, abdomen, chest and extremities, sometimes with neuro findings on exam. Diagnosis is by MRI (94% sensitive). Keep a high index of suspicion, yada, yada…
26. CORTICOSTEROID INJECTIONS IN THE TREATMENT OF TRIGGER FINGER: A LEVEL I AND II SYSTEMATIC REVIEW, Fleisch, S.B., et al, J Am Acad Orth Surg 15(3):166, March 2007 : Very little data on the practice, none of it well done, showing 50% of patients appear to improve. In appropriate patients, due to low risk and simplicity of procedure, it is worth a shot (get it? Oh, never mind.)
27. ACUTE ROTATOR CUFF TEAR: DO WE MISS THE EARLY DIAGNOSIS? A PROSPECTIVE STUDY SHOWING A HIGH INCIDENCE OF ROTATOR CUFF TEARS AFTER SHOULDER TRAUMA, Sorensen, A.K.B., et al, J Shoulder Elbow Surg 16:174, March/April 2007 : Poor correlation between blinded physical exam and ultrasound findings, showing frequent missed tears, especially in the older patient population. Not sure how diagnosing tear in ED changes anything, but may be helpful to tell patients there may be a tear, may need treatment for it later.
28. IN CHILDREN UNDER AGE THREE DOES PROCALCITONIN HELP EXCLUDE SERIOUS BACTERIAL INFECTION IN FEVER WITHOUT FOCUS?, Herd, D., Arch Dis Child 92:362, April 2007 : Baseline risk of bacteremia in the Hib vaccine era is <2%. Procalcitonin is sensitive, but probably not useful enough to exclude bacteremia.
29. RANDOMIZED DOUBLE-BLIND PLACEBO-CONTROLLED TRIAL OF TWO INTRAVENOUS MORPHINE DOSAGES (0.10MG/KG AND 0.15MG/KG) IN EMERGENCY DEPARTMENT PATIENTS WITH MODERATE TO SEVERE ACUTE PAIN, Birnbaum, A., et al, Ann Emerg Med 49(4):445, April 2007 : More morphine, slightly better pain relief, with no downside risk. MY PERSONAL TAKE: Treat pain and reassess. You can always give more morphine.
30. THE FDA AND THE CASE OF KETEK, Ross, D.B., N Engl J Med 356(16):1601, April 19, 2007 : Fraud in the studies; FDA in the pocket of the drug companies. Evil everywhere.
31. A NATIONAL SURVEY OF PHYSICIAN-INDUSTRY RELATIONSHIPS, Campbell, E.G., et al, N Engl J Med 356(17):1742, April 26, 2007 : Many surveyed docs took bribes, I mean food, CME money, and ‘gifts’ from drug reps. Cardiologists and FP’s are the most likely to report getting stuff.
32. PHARMACEUTICAL COMPANY PAYMENTS TO PHYSICIANS: EARLY EXPERIENCES WITH DISCLOSURE LAWS IN VERMONT AND MINNESOTA, Ross, J.S., et al, JAMA 297(11):1216, March 21, 2007: Lots of payments still being made, and access to supposed public documents were not available. Evil pharmaceutical companies again.
33. LOW-DOSE PROPOFOL REDUCES THE INCIDENCE OF MODERATE TO SEVERE LOCAL PAIN INDUCED BY THE MAIN DOSE, Liljeroth, E., et al, Acta Anesthesiol Scand 51(4):460, April 2007 : Using a small priming dose of propofol ameliorates some of the discomfort associated with injection, but not compared to lidocaine, only placebo. Probably not worth the effort.
34. PEDIATRIC PROCEDURAL SEDATION IN THE COMMUNITY EMERGENCY DEPARTMENT: RESULTS FROM THE PRO-SCED REGISTRY, Sacchetti, A., et al, Ped Emerg Care 23(4):218, April 2007 : Over 1000 patients, with one case of apnea and one case of hypoxemia. Bottom line: Sedation of kids for procedures in the ED is very safe and effective.
35. EFFECTS OF REPLACING OXITROPIUM WITH TIOTROPIUM ON PULMONARY FUNCTION IN PATIENTS WITH COPD, Incorvaia, C., et al, Resp Med 101(3):476, March 2007 : Bad study. Some improvement in pulm function tests with Spiriva, but no real outcomes measured.
36. SYSTEMIC CORTICOSTEROIDS IN CHRONIC OBSTRUCTIVE PULMONARY DISEASE: AN OVERVIEW OF COCHRANE SYSTEMATIC REVIEWS, Wood-Baker, R., et al, Resp Med 101(3):371, March 2007 : Not helpful in stable COPD with risk of adverse events (Number needed to harm: 9).
37. DECLINING ANTIBIOTIC PRESCRIPTIONS FOR UPPER RESPIRATORY INFECTIONS, 1993-2004, Vanderweil, S.G., et al, Acad Emerg Med 14(4):366, April 2007 : We are still giving abx for viral URI’s in up to 1/3rd of patients with that diagnosis. Stop. Now.
38. THROAT CULTURE IS NECESSARY AFTER NEGATIVE RAPID ANTIGEN DETECTION TESTS., Mirza, A., et al, Clin Ped 46(3):241, April 2007 : About 7% of neg rapid stress tests followed by cultures were positive. The authors suggest culture everyone. I say do neither, but treat appropriately based on clinical criteria (Centor criteria: fever, tender lympadenopathy, exudates, absence of uri symptoms).
39. EMERGENCY ROOM MANAGEMENT OF PATIENTS WITH BLUNT MAJOR TRAUMA: EVALUATION OF THE MULTISLICE COMPUTED TOMOGRAPHY PROTOCOL EXEMPLIFIED BY AN URBAN TRAUMA CENTER, Weninger, P., et al, J Trauma 62:584, March 2007 : Weird study, small-volume resuscitation and intubation (if needed) by pre-hospital physicians followed by immediate transfer to CT from ambulance. Pan-scanning upon arrival included: head, face, c-spine, chest, abd/pelvis. Post-protocol implementation showed less MSOF, shorter ED, CU and hospital stays, but no mortality difference. Is this really where we want to go?
40. THE INCREASING USE OF CHEST COMPUTED TOMOGRAPHY FOR TRAUMA: IS IT BEING OVERUTILIZED?, Plurad, D., et al, J Trauma 62(3):631, March 2007 : CT chest went from 2.7% in 1998 to 28.7% in 2004, but only 12 occult injuries found were actually treated. Opposite of above, article. Bottom line of these two: Think before you order that CT.

2007-08-17T16:12:00.000-07:00

July EMA Abstracts

1. WEEKEND VERSUS WEEKDAY ADMISSION AND MORTALITY FROM MYOCARDIAL INFARCTION Kostis, W.J., et al, N Engl J Med 356(11):1099, March 15, 2007: Lower utilization of PCI and CABG immediately and short term. Slightly higher 30-day mortality (12.9 v. 12.0%). Key point: Have your MI during the week.
2. DIAGNOSTIC VALUE OF 64-SLICE MULTI-DETECTOR ROW CARDIAC CTA IN SYMPTOMATIC PATIENTS Muhlenbruch, G., et al, Eur Radiol 17(3):603, March 2007: Only moderate agreement in symptomatic, high risk patients compared to cath. Leads to some questions as to benefit in these high risk patients.
3. A RANDOMIZED CONTROLLED TRIAL OF MULTI-SLICE CORONARY COMPUTED TOMOGRAPHY FOR EVALUATION OF ACUTE CHEST PAIN Goldstein, J.A., et al, J Am Coll Card 49(8):863, February 27, 2007: 67% were normal and discharged, 8% clearly abnormal and went to cath, and 25% needed standard work-up. For low risk patients, this may be an interesting paradigm.
4. CLINICAL AND ECONOMIC IMPACT OF STRESS ECHOCARDIOGRAPHY COMPARED WITH EXERCISE ELECTROCARDIOGRAPHY IN PATIENTS WITH SUSPECTED ACUTE CORONARY SYNDROME BUT NEGATIVE TROPONIN Jeetley, P., et al, Eur Heart J 28(2):204, January 2007: Stress echo categorized more patients as low risk, but more of these patients had events (5% v. 3%, NS) on follow-up. This is not helpful.
5. LONG-TERM OUTCOME AFTER AN EARLY INVASIVE VERSUS SELECTIVE INVASIVE TREATMENT STRATEGY IN PATIENTS WITH NON-ST-ELEVATION ACUTE CORONARY SYNDROME AND ELEVATED CARDIAC TROPONIN T (THE ICTUS TRIAL): A FOLLOW- UP STUDY Hirsch, A., et al, Lancet 369:827, March 10, 2007: No advantage to immediate PCI in non-STEMI. Early increase in MI with early invasive management!
6. CARDIAC CATHETERISATION: RADIATION DOSES AND LIFETIME RISK OF MALIGNANCY Vijayalakschmi, K., et al, Heart 93:370, March 2007: Depending on type of study performed, radiation risk estimated excess cancer deaths range from 1 in 3000 to 1 in 9000.
7. PROBLEMS WITH USE OF COMPOSITE END POINTS IN CARDIOVASCULAR TRIALS: SYSTEMATIC REVIEW OF RANDOMISED CONTROLLED TRIALS Ferreira-Gonzalez, I., et al, Br Med J 334:786, April 2007: Composite endpoints often include clinically insignificant endpoints, which often are the only differences between interventions. What appears to be a significant difference may not be so significant for real outcomes. Use caution when looking at studies with composite endpoint.
8. NEUROLOGIC SYMPTOMS IN TYPE A AORTIC DISSECTIONS Gaul, C., et al, Stroke 38:292, February 2007: Another study showing it is hard to diagnose TAD. More misdiagnosis if patients presents with neuro symptoms only. Higher mortality noted. Fatal event noted with TPA treatment. Bad disease.
9. CARDIOPULMONARY RESUSCITATION BY BYSTANDERS WITH CHEST COMPRESSION ONLY (SOS-KANTO): AN OBSERVATIONAL STUDY Nagao, K., et al, Lancet 369:920, March 17, 2007 : No differences in outcome noted with compression only bystander CPR compared to conventional CPR/MMR.
10. YIELD AND UTILITY OF RADIOGRAPHIC "SHUNT SERIES" IN THE EVALUATION OF VENTRICULO-PERITONEAL SHUNT MALFUNCTION IN ADULT EMERGENCY PATIENTS Griffey, R.T., et al, Emerg Radiol 13(6):307, March 2007: Only 3% had an abnormal shunt series with a normal CT. Unclear if any utility to doing shunt series.
11. THE EFFECT OF FRESH FROZEN PLASMA IN SEVERE CLOSED HEAD INJURY Etemadrezaie, H., et al, Clin Neurol Neurosurg 109:166, February 2007: Unfortunately the FFP group was worse to begin with and did worse. No benefit seen, and maybe FFP is worse.
12. SAFETY OF RAPID INTRAVENOUS VALPROATE INFUSION IN PEDIATRIC PATIENTS Morton, L.D., et al, Ped Neurol 36(2):81, February 2007: Small study. Seems to be safe.
13. SAFETY OF RAPID INTRAVENOUS LOADING OF VALPROATE Limdi, N.A., et al, Epilepsia 48(3):478, March 2007: Small study, seems to be safe. Frequent burning @ infusion site.
14. COMMUNITY-ONSET METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS SKIN AND SOFT TISSUE INFECTIONS: IMPACT OF ANTIMICROBIAL THERAPY ON OUTCOME Ruhe, J.J., et al, Clin Infect Dis 44:777, March 15, 2007: I&D seems to be effective even if abx choice wrong. Low failure rate. More study needed. Continue to use MRSA appropriate abx (i.e. clindamycin) in our population.
15. TIME SERIES ANALYSIS OF VARIABLES ASSOCIATED WITH DAILY MEAN EMERGENCY DEPARTMENT LENGTH OF STAY Rathlev, N.K., et al, Ann Emerg Med 49(3):265, March 2007: Number of ED admits, number of elective surgical cases and increased IP occupancy accounted for a lot of the variability in ED LOS – factors often outside the control of the ED. ED LOS is a hospital-wide issue!
16. THE EFFECT OF LOW-COMPLEXITY PATIENTS ON EMERGENCY DEPARTMENT WAITING TIMES Schull, M.J., et al, Ann Emerg Med 49(3):257, March 2007: 50% of patients in ED are ‘low complexity’. They had minimal impact on overall ED LOS and time for patients to be seen. This is not the ED LOS and overcrowding problem.
17. COST-EFFECTIVENESS ANALYSIS OF TREATMENT OPTIONS FOR ACUTE OTITIS MEDIA Coco, A.S., Ann Fam Med 5(1):29, January/February 2007: WASP or giving amoxicillin equally (and poorly) cost-effective.
18. CAN URINE CULTURES AND REAGENT TEST STRIPS BE USED TO DIAGNOSE URINARY TRACT INFECTION IN ELDERLY EMERGENCY DEPARTMENT PATIENTS WITHOUT FOCAL URINARY SYMPTOMS? Ducharme, J., et al, Can J Emerg Med 9(2):87, March 2007: No.
19. EFFICACY OF ALPHA-BLOCKERS FOR THE TREATMENT OF URETERAL STONES Parsons, J.K., et al, J Urol 177:983, March 2007: Meta-analysis showed alpha blockers increased passage of stones. TAKE HOME POINT: Use alpha-blockers (i.e. Flomax 0.4mg po qd) when discharging patients with ureteral stones!
20. THROMBOEMBOLIC COMPLICATIONS ASSOCIATED WITH FACTOR VIIA ADMINISTRATION Rhys Thomas, G.O., et al, J Trauma 62:564, March 2007: TAKE HOME POINT: Thromboembolic complications in 10% of treated patients, some fatal. Use extreme care when using this drug (Novo-7).
21. DROTRECOGIN ALFA (ACTIVATED) IN CHILDREN WITH SEVERE SEPSIS: A MULTICENTRE PHASE III RANDOMISED CONTROLLED TRIAL Nadel, S., et al, Lancet 369:836, March 10, 2007: TAKE HOME POINT: Xigris did not show benefit in children with severe sepsis. May be worse in kids under 2 months. Bad, even in this industry sponsored trial.
22. CLINICAL AND LABORATORY FEATURES, HOSPITAL COURSE, AND OUTCOME OF ROCKY MOUNTAIN SPOTTED FEVER IN CHILDREN Buckingham, S.C., et al, J Ped 150:180, February 2007: Most had fever and rash, but less than half had fever, rash and history of tick attachment. Often delayed diagnosis and treatment. Some bad outcomes.
23. DO PERIPHERAL BLOOD CULTURES TAKEN IN THE EMERGENCY DEPARTMENT INFLUENCE CLINICAL MANAGEMENT? Munro, P.T., et al, Emerg Med J 24:211, March 2007: Only 1.4% had true positive blood cultures. Only 0.18% had management changed based on ED blood culture results. Think before you order the blood culture.
24. LATE VS. EARLY CLAMPING OF THE UMBILICAL CORD IN FULL-TERM NEONATES: SYSTEMATIC REVIEW AND META-ANALYSIS OF CONTROLLED TRIALS Hutton, E.K., et al, JAMA 297(11):1241, March 21, 2007: Meta-analysis. Clamp cord immediately or wait 2 minutes. Answer: probably wait 2-minutes, but no clear answer despite 15 studies.
25. DOES THIS ADULT PATIENT HAVE SEPTIC ARTHRITIS? Margaretten, M.E., et al, JAMA 297(13):1478, April 4, 2007: ESR and CRP not helpful. Very high peripheral WBC (>25) increases risk. TAKE HOME POINT: If you want to know, tap the joint.
26. APPLICATION OF CLINICAL CRITERIA FOR ORDERING RADIOGRAPHS TO DETECT CERVICAL SPINE FRACTURES Moscati, R.M., et al, Am J Emerg Med 25:325, March 2007: Once again, clinical criteria are safe/effective/cost effective. Think before you order the c-spine series.
27. DOSE AND TIME-DEPENDENT EFFECTS OF CYCLOOXYGENASE-2 INHIBITION ON FRACTURE HEALING Simon, A.M., et al, J Bone Joint Surg 89A(3):500, March 2007: Animal model of femur fx shows impairment of healing if used early in post-fx period. TAKE HOME POINT: Avoid use of NSAIDS and COX-2i’s in acute fx patients.
28. ACUTE TREATMENT OF INVERSION ANKLE SPRAINS Jones, M.H., et al, Clin Orth Rel Res 455:169, February 2007: Systematic review indicates early mobilization rather than splinting, but patients prefer immobilization.
29. THE ROLE OF PELVIC MAGNETIC RESONANCE IN EVALUATING NONHIP SOURCES OF INFECTION IN CHILDREN WITH ACUTE NONTRAUMATIC HIP PAIN Karmazyn,T B., et al, Ped Orth 27(2):158, March 2007: Consider MR in kids with hip pain with either fever, increased ESR or elevated WBC and neg hip taps but look sick.
30. PRIMARY REPAIR VERSUS CONSERVATIVE TREATMENT OF FIRST-TIME TRAUMATIC ANTERIOR DISLOCATION OF THE SHOULDER: A RANDOMIZED STUDY WITH 10-YEAR FOLLOW-UP Jakobsen, B.W., et al, Arthroscopy 23(2):118, February 2007: Interesting study. Many conservatively treated patients had recurrences or other problems, with less seen in surgically treated patients.
31. ALTERNATING ANTIPYRETICS FOR FEVER REDUCTION IN CHILDREN: AN UNFOUNDED PRACTICE PASSED DOWN TO PARENTS FROM PEDIATRICIANS Wright, A.D., et al, Clin Ped 46(2):146, March 2007: No evidence to support alternating regimens, but it is often recommended by pediatricians from parents.
32. CLINICAL PREDICTORS OF OCCULT PNEUMONIA IN THE FEBRILE CHILD Murphy, C.G., et al, Acad Emerg Med 14(3):243, March 2007: No clinical criteria were sensitive enough to exclude occult pneumonia.
33. DO ALL INFANTS WITH APPARENT LIFE-THREATENING EVENTS NEED TO BE ADMITTED? Claudius, I., et al, Pediatrics 119(4):679, April 2007: Gest age < 37 wks, multiple events, age less than 1 month all require admission. All others would have done well, but very small initial study.
34. A RANDOMIZED, CONTROLLED TRIAL OF ACETAMINOPHEN, IBUPROFEN AND CODEINE FOR ACUTE PAIN RELIEF IN CHILDREN WITH MUSCULOSKELETAL TRAUMA Clark, E., et al, Pediatrics 119(3):460, March 2007: Ibuprofen tended to have better pain relief than Tylenol or codeine.
35. SHOULD PULMONARY EMBOLISM BE SUSPECTED IN EXACERBATION OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE? Rutschmann, O.T., et al, Thorax 62:121, February 2007: 3.3% of patients had PE when no other source of exacerbation was identified. Consider D-Dimer in these patients and look further (Dopplers and CT) if positive.
36. OPIATE THERAPY IN CHRONIC COUGH Morice, A.H., et al, Am J Resp Crit Care Med 175(4):312, February 15, 2007: Moderate improvement in well done study with morphine for chronic cough (5mg bid).
37. ANTIBIOTICS FOR BACTEREMIC PNEUMONIA: IMPROVED OUTCOMES WITH MACROLIDES BUT NOT FLUOROQUINOLONES Metersky, M.L., et al, Chest 131(2):466, February 2007: Macrolides had decreased mortality and readmission, and were better than fluoroquinolones and tetracycline.
38. PROPER INSERTION DEPTH OF ENDOTRACHEAL TUBES IN ADULTS BY TOPOGRAPHIC LANDMARKS MEASUREMENTS Evron, S., et al, J Clin Anesth 19(1):15, February 2007: Add distance from angle of mouth to angle of jaw and angle of jaw to midline of manubrium, positioned better than 21 cm for women and 23 cm for men. I won’t start doing this, as no actual clinical benefit noted.
39. SUGAMMADEX REVERSAL OF ROCURONIUM-INDUCED NEUROMUSCULAR BLOCKADE: A COMPARISON WITH NEOSTIGMINE-GLYCOPYRROLATE AND EDROPHONIUM-ATROPINE, Sacan, O., et al, Anesth Analg 104(3):569, March 2007: Reversal of nmb with this drug was faster than with neostigmine/glycopyrrolate or edrophonium. Nice tool to have, but probably won’t be used in the ED.
40. PROPHYLACTIC ANTIBIOTICS ARE NOT INDICATED IN UNCOMPLICATED HAND LACERATIONS, Al-Nammari, S.S., Emerg Med J 24:218, March 2007: The title says it all.

June EMA Abstracts

2007-07-29T16:47:00.000-07:00

1. EMERGENCY DEPARTMENT MANAGEMENT AND SHORT-TERM OUTCOME OF CHILDREN WITH CONSTIPATION, Miller, M.K., et al, Ped Emerg Care 23(1):1, January 2007: Frequent presenting complaint. Wide variability in workup and treatment. Poor response to treatment in 42%. About 40% had prior visits and a quarter had further visits for same complaint. No big message here.
2. THE ROLE OF CARDIAC RISK FACTOR BURDEN IN DIAGNOSING ACUTE CORONARY SYNDROMES IN THE EMERGENCY DEPARTMENT SETTING, Han, J.H., et al, Ann Emerg Med 49(2):145, February 2007: Cardiac risk factors are useful for populations, but are not helpful in acute ED presentations, except for possibly in those under 40. Bottom line: If they have a lot of risk factors, let the cardiologist know, because they will still be impressed. If they have no or few risk factors, let them know how typical the presentation is. Nothing new here.
3. RELATIONSHIP BETWEEN A CLEAR-CUT ALTERNATIVE NONCARDIAC DIAGNOSIS AND 30-DAY OUTCOME IN EMERGENCY DEPARTMENT PATIENTS WITH CHEST PAIN, Hollander, J.E., et al, Acad Emerg Med 14(3):210, March 2007: Patients with clear-cut alternative diagnosis for chest pain still had bad outcomes 4% of time (versus 8% with no other diagnosis found in ED). Not really helpful in acute presentations.
4. COMPARISON OF EARLY MORTALITY OF PARAMEDIC-DIAGNOSED ST-SEGMENT ELEVATION MYOCARDIAL INFARCTION WITH IMMEDIATE TRANSPORT TO A DESIGNATED PRIMARY PERCUTANEOUS CORONARY INTERVENTION CENTER TO THAT OF SIMILAR PATIENTS TRANSPORTED TO THE NEAREST HOSPITAL, Le May, M.R., et al, Am J Cardiol 98(10):1329, November 15, 2006: Two points: Early PCI versus thrombolyisis results in lower mortality (duh), and paramedics can be taught to do and read 12-leads relatively accurately.
5. THE DIAGNOSTIC ACCURACY OF 64-SLICE COMPUTED TOMOGRAPHY CORONARY ANGIOGRAPHY COMPARED WITH STRESS NUCLEAR IMAGING IN EMERGENCY DEPARTMENT LOW-RISK CHEST PAIN PATIENTS, Gallagher, M.J., et al, Ann Emerg Med 49(2):125, February 2007: Very small study showing 86% sensitivity and 92% specificity for Cardiac CT angiography in low risk patients (similar to stress testing). Needs large study with good follow-up to make any recommendation on this.
6. ROUTINE UPSTREAM INITIATION VS. DEFERRED SELECTIVE USE OF GLYCOPROTEIN IIB/IIIA INHIBITORS IN ACUTE CORONARY SYNDROMES: THE ACUITY TIMING TRIAL, Stone, G.W., et al, JAMA 297(6):591, February 14, 2007 : Should we start GPIIb/IIIa inhibitors in the ED or wait until cath lab shows lesion that requires intervention? No difference in outcome with less bleeding events in cath lab started group. Look for more on this.
7. A QUALITY GUARANTEE IN ACUTE CORONARY SYNDROMES: THE AMERICAN COLLEGE OF CARDIOLOGY'S GUIDELINES APPLIED IN PRACTICE PROGRAM TAKEN REAL-TIME, Vasaiwala, S., et al, Am Heart J 153(1):16, January 2007 Real-time monitoring of quality markers done while patient is still in hospital improves compliance with MOR criteria compared with just looking at it after the fact. Another duh kind of paper. Would it be possible to do this at our hospitals? Doubt it.
8. HEART FAILURE WITH A NORMAL EJECTION FRACTION, Sanderson, J.E., Heart 93:155, February 2007: Probably related to long-standing HTN and wall stiffness. No good EBM guidelines on how to treat, but probably use diuresis for acute treatment and long term treatment with ACE or ARB.
9. INCREASING USE OF CARDIOPULMONARY RESUSCITATION DURING OUT-OF- HOSPITAL VENTRICULAR FIBRILLATION ARREST: SURVIVAL IMPLICATIONS OF GUIDELINE CHANGES, Rea, T.D., et al, Circulation 114:2760, December 19-26, 2006 : More CPR, less time checking in vfib arrests improves outcome. Difficult to believe the data (as usual) from Seattle where everyone survives.
10. TRANSTHORACIC INCREMENTAL MONOPHASIC VERSUS BIPHASIC DEFIBRILLATION BY EMERGENCY RESPONDERS (TIMBER)Kudenchuk, P.J., et al, Circulation 114:2010, November 7, 2006 : No outcome difference between monophasic and biphasic shocks.
11. CALCULATING THE REQUIRED TRANSFUSION VOLUME IN CHILDREN, Davies, P., et al, Transfusion 47:212, February 2007 : 10 ml/kg transufusion volume leads to 2 gm/dl Hb increase – reasonable recommendation but based on poor methods.
12. VALIDATION OF THE ABCD SCORE IN IDENTIFYING INDIVIDUALS AT HIGH EARLY RISK OF STROKE AFTER A TRANSIENT ISCHEMIC ATTACK: A HOSPITAL- BASED CASE SERIES STUDY, Tsivgoulis, G., et al, Stroke 37:2892, December 2006 : Previously studied score to differentiate TIA patients with high and low risk for subsequent stroke is not sensitive enough to decide who to send home. Bottom line: Admit TIA’s for work-up for reversible or preventable causes to limit risk of debilitating subsequent stroke.
13. VALIDATION AND REFINEMENT OF SCORES TO PREDICT VERY EARLY STROKE RISK AFTER TRANSIENT ISCHAEMIC ATTACK, Johnston, S.C., et al, Lancet 369:283, January 27, 2007 : Despite complicating the assessment tool, you still can’t discharge TIA patients from the ED (see above)
14. ANALYSIS OF EMPIRIC ANTIMICROBIAL STRATEGIES FOR CELLULITIS IN THE ERA OF METHICILLIN-RESISTANT STAPHYLOCOCCUS AUREUS Phillips, S., et al, Ann Pharmacother 41:13, January 2007 : Theoretical cost study shows that keflex is more cost effective if MRSA is unlikely, but clinda if high risk. Bottom line: We have high risk – use anti-MRSA meds for cellulitis.
15. CHARACTERISTICS AND TEMPORAL TRENDS OF "LEFT BEFORE BEING SEEN" VISITS IN US EMERGENCY DEPARTMENTS, 1995-2002, Sun, B.C., et al, J Emerg Med 32(2):211, February 2007 : Rate of LWBS is increasing over time (estimated at 1.92% in 2002), with younger, non-urgent, non-white, urban, uninsured being more likely to leave. Numbers probably higher now. With our yellow pod and nursing changes, our numbers are in this ballpark.
16. EXTRACTS FROM THE COCHRANE LIBRARY: ANTIHISTAMINES AND/OR DECONGESTANTS FOR OTITIS MEDIA WITH EFFUSION (OME) IN CHILDREN, Burton, M.J., et al, Otolaryngol Head Neck Surg 136(1):11, January 2007 : Doesn’t work, may harm. Don’t use them.
17. IS SKIN TURGOR RELIABLE AS A MEANS OF ASSESSING HYDRATION STATUS IN CHILDREN?, Fayomi, O., Emerg Med J 24:124, February 2007 : Only moderate inter-rater agreement. Utility not addressed.
18. META-ANALYSIS: ONDANSETRON FOR VOMITING IN ACUTE GASTROENTERITIS IN CHILDREN, Szajewska, H., et al, Aliment Pharmacol Ther 25(4):393, February 2007 : May be beneficial in some patients. May increase diarrhea. I have asked pharmacy to look into cost issues at CHW for us.
19. PAEDIATRIC INTUSSUSCEPTION: EPIDEMIOLOGY AND OUTCOME, Blanch, A.J.M., et al, Emerg Med Australasia 19(1):45, February 2007 : 94% ≤ 4yo, M:F = 2:1, often not classic presentation, frequently present with lethargy and irritability diagnosis missed initially 46% of time. Bottom line: think about this diagnosis.
20. POINT-OF-CARE URINE TRYPSINOGEN TESTING FOR THE DIAGNOSIS OF PANCREATITIS, Jang, T., et al, Acad Emerg Med 14(1):29, January 2007 : Amylase and lipase are not that accurate at times, but do we really have that much difficulty diagnosing pancreatitis? Do we need to make this diagnosis with a POC testing immediacy? No and no. So why do you even care about the results of this study? Look for bigger, better studies on this.
21. SIMPLE CLINICAL PREDICTORS MAY OBVIATE URGENT ENDOSCOPY IN SELECTED PATIENTS WITH NONVARICEAL UPPER GASTROINTESTINAL TRACT BLEEDING, Romagnuolo, J., et al, Arch Intern Med 167:265, February 12, 2007 : Impressive results in small study for clinical and lab findings looking for low risk for rebleeding or complications. But still risk present even with very low risk patients. Look for follow-up studies.
22. BLIND URETHRAL CATHETERIZATION IN TRAUMA PATIENTS SUFFERING FROM LOWER URINARY TRACT INJURIES, Shlamovitz, G.Z., et al, J Trauma 62:330, February 2007 : Small study. Reasonable to attempt a single, ‘gentle’ attempt at placing a Foley without evidence of increased injury.
23. CLINICAL PREDICTION RULE TO DISTINGUISH PELVIC INFLAMMATORY DISEASE FROM ACUTE APPENDICITIS IN WOMEN OF CHILDBEARING AGE, Morishita, K., et al, Am J Emerg Med 25:152, February 2007 : Low risk for appendicitis: no pain migration, absence of n/v and presence of bilat tenderness. Still some patients had appendicitis. No take-home point here.
24. FEVER AFTER A STAY IN THE TROPICS: DIAGNOSTIC PREDICTORS OF THE LEADING TROPICAL CONDITIONS, Bottieau, E., et al, Medicine 86(1):18, January 2007 : Think malaria with early onset fever with splenomegaly, thrombocytopenia, hyperbilirubinemia and absence of localizing source of fever. Think of tropical illnesses in any patient within one month of return. Late onset was often non-falciparum fever. Break-bone fever – dengue.
25. COMPARISON OF LABORATORY VALUES OBTAINED BY PHLEBOTOMY VERSUS SALINE LOCK DEVICES, Corbo, J., et al, Acad Emerg Med 14(1):23, January 2007 : No significant differences statistically and no clinical difference between paired tests. Useful take-home point: Saline-lock drawn blood is accurate for commonly used lab tests including potassium.
26. THE NATIONAL TREND IN QUALITY OF EMERGENCY DEPARTMENT PAIN MANAGEMENT FOR LONG BONE FRACTURES, Ritsema, T.S., et al, Acad Emerg Med 14(2):163, February 2007 : Some improvement over time in use of analgesics for fractures, but we are still not doing well. Broken bone should = good drugs.
27. CAN A NORMAL RANGE OF ELBOW MOVEMENT PREDICT A NORMAL ELBOW X-RAY?, Lennon, R.I., et al, Emerg Med J 24:86, February 2007 : 97% NPV for full pronation, full supination, full flexion and full extension – very low risk.
28. COMPUTED TOMOGRAPHY OF SUSPECTED SCAPHOID FRACTURES, Adey, L., et al, J Hand Surg 32A(1):61, January 2007 : CT is better than plain films but not perfect. Do not use this in the ED. Treat xray or conservatively on clinical findings. No change in your management because of this study.
29. ASSESSMENT OF UPPER GASTROINTESTINAL SAFETY OF ETORICOXIB AND DICLOFENAC IN PATIENTS WITH OSTEOARTHRITIS AND RHEUMATOID ARTHRITIS IN THE MULTINATIONAL ETORICOXIB AND DICLOFENAC ARTHRITIS LONG-TERM (MEDAL) PROGRAMME: A RANDOMISED COMPARISON, Laine, L., et al, Lancet 369:465, February 10, 2007 : Statistically significant but clinically insignificant differences comparing an NSAID with high gi effects. Bad industry sponsored study.
30. NSAID USE AND PROGRESSION OF CHRONIC KIDNEY DISEASE, Gooch, K., et al, Am J Med 120(3):280.e1, March 2007 : Complex study, but possibly more NSAID use associated with higher risk of progression of kidney disease. Not a study to change management in the ED.
31. A RANDOMIZED CONTROLLED TRIAL COMPARING INTRANASAL FENTANYL TO INTRAVENOUS MORPHINE FOR MANAGING ACUTE PAIN IN CHILDREN IN THE EMERGENCY DEPARTMENT, Borland, M., et al, Ann Emerg Med 49(3):335, March 2007 : Essentially equivalent. Not powered for safety.
32. THE COST OF OVER-THE-COUNTER SUBSTANCE ABUSE, Feinberg, D.T., J Child Adol Psychopharm 16(6):801, December 2006 : 10% of teens abuse OTC meds, with dextromethorphan being the most common.
33. COMPARISON OF URINARY ON-SITE IMMUNOASSAY SCREENING AND GAS CHROMATOGRAPH-MASS SPECTROMETRY RESULTS OF 111 PATIENTS WITH SUSPECTED POISONING PRESENTING AT AN EMERGENCY DEPARTMENT, von Mach, M.A., et al, Ther Drug Monit 29(1):27, February 2007 : Rapid POC assay (Biosite Triage 8) is frequently worng (50% took something not measured on the assay and 20% had discordant results). Not accurate or helpful.
34. EFFECT OF NAIL POLISH ON OXYGEN SATURATION DETERMINED BY PULSE OXIMETRY IN CRITICALLY ILL PATIENTS, Hinkelbein, J., et al, Resuscitation 72:82, January 2007 : Nice little study. Nail polish does not seem to affect readings by more than 1.6%. Take-home: Leave the nail-polish on.
35. WHAT IS THE ROLE OF CHEST X-RAY IN THE INITIAL ASSESSMENT OF STABLE TRAUMA PATIENTS?, Wisbach, G.G., et al, J Trauma 62:74, January 2007 : Bad study with correct answer: No utility in hemodynamically stable patients with no chest complaints.
36. EFFECT OF AZITHROMYCIN AND CLARITHROMYCIN THERAPY ON PHARYNGEAL CARRIAGE OF MACROLIDE-RESISTANT STREPTOCOCCI IN HEALTHY VOLUNTEERS: A RANDOMISED, DOUBLE-BLIND, PLACEBO-CONTROLLED STUDY, Malhotra-Kumar, S., et al, Lancet 369:482, February 10, 2007 : Yet another reason to not treat URI with abx: Increase in macrolide resisitant bacteria after a brief course of macrolides.
37. COMPARISON BETWEEN SINGLE-DOSE ORAL PREDNISOLONE AND ORAL DEXAMETHASONE IN THE TREATMENT OF CROUP: A RANDOMIZED, DOUBLE-BLINDED CLINICAL TRIAL, Fifoot, A.A., et al, Emerg Med Australasia 19(1):51, February 2007 : Although dexamethasone is standard, no difference between these steroids.
38. EFFICACY OF ANTIBIOTIC PROPHYLAXIS FOR INTRAFAMILIAL TRANSMISSION OF GROUP A BETA-HEMOLYTIC STREPTOCOCCI, Kikuta, H., et al, Ped Infect Dis J 26(2):139, February 2007 : Low rate of familial transmission to begin with resulted in no useful benefit. Useful info: familial transmission rate about 5% to sibs.
39. ARE SORE THROAT PATIENTS WHO HOPE FOR ANTIBIOTICS ACTUALLY ASKING FOR PAIN RELIEF?, van Driel, M.L., et al, Ann Fam Med 4(6):494, November/December 2006 : UK study, but those patients wanted a diagnosis and pain relief more than abx. Bottom line: Treat the pain, talk to the patient, hold abx unless absolutely needed.
40. RADIATION EXPOSURE FROM DIAGNOSTIC IMAGING IN SEVERELY INJURED TRAUMA PATIENTS, Tien, H.C., et al, J Trauma 62(1):151, January 2007 : Excess cancer deaths 1 in 500 trauma patients (by estimates from dosimeters). Be careful what you order.

May Abstracts

2007-05-28T14:14:00.000-07:00

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.

March Abstracts

2007-04-28T13:22:00.000-07:00

Ogawa, A., et al, Circ J 70:1372, November 2006: Japanese study looking at pro-BNP in suspected ACS w/o CHF. They compared it to traditional cardiac markers. pro-BNP was much higher in NSTEMI vs STEMI pts. Poorly constructed study w/ lots of data mining. Nothing here should change your management.
LeMay, M.R., et al, Am J Emerg Med 8(6):401, November 2006: Pre-hospital EKG interpretation of EMT's in Ottawa w/ theoretical administration of thrombolytics. They would have overtreated some cases and only saved 44 minutes on average. Since we prefer PCI, nothing here will alter much.
Bradley, E.H., et al, N Engl J Med 355(22):2308, November 30, 2006: Yale study looking at door-to-balloon time. Average time across the nation was 100 minutes. You can improve your steps by having a single page operator, cath staff required to be present by 20 minutes, an in-house cardiologist, the ED doc can call the cath team in and real-time feedback to the ED.
Chung, T., et al, Am Heart J 152:949, November 2006: They examined the utility of BNP in the ED for patients w/ dyspnea. BNP testing was worse in pts w/ a h/o of CHF vs. those w/ a new history. Again, my personal approach is history, physical exam, CXR and the clinical picture will provide all the info you need for whether it's CHF. I don't order this test anymore.
Bursi, F., et al, JAMA 296(18):2209, November 8, 2006: Systolic vs. diastolic dysfunction in pts w/ CHF. Diastolic failure will have decent EF but poor filling of the chambers due to wall resistance. They performed an echo and almost 1/2 of pts w/ CHF didn't have systolic dysfunction (greater than 50%). BNP was mean of 380 in systolic and 183 in diastolic failure. 6 month mortality was 16% for both groups.
Busch, M., et al, Acta Anaesthesiol Scand 50:1277, 2006: Induced therapeutic hypothermia for out-of-hospital cardiac arrest who got a spontaneous return of circulation. Small group (N: 27), cooled to 33 degrees for 12 hours. Slightly more than half survived (but no mention of neuro outcome). Median time to receive target temp was 7.5 hours.
Blaivas, M., et al, J Emerg Med 31(4):407, November 2006: At the Medical College of Georgia, they taught nurses how to use an U/S to enable IV access for difficult pts for obtaining an IV. They had 89% of success rate utilizing the SonoSite. Something we may want to look at (Evan...)
Humm, A.M., et al, J Neurol Neurosurg Psych 77(11):1267, November 2006: Carotid sinus hypersensitivity as a cause of syncope. Defined by asystole greater than 3 secs and/or drop in SBP by 50. This is a technically difficult dx to make. Only 1 in 40 of pts b/w 40-60 had a positive test. Over 80 yrs old, 40% had it (but did it cause the syncope?). Either way, it's not worthwhile to make it a routine test to determine whether it caused the syncope.
Baden, E.Y., et al, Can J Emerg Med 8(6):393, November 2006: IV dexamethasone prior to discharge for ED pts w/ benign H/A. They've been treated and are ready to go home. Treated w/ either placebo or Decadron 10 mg IV. 58% of pts w/ placebo still had a H/A as follow-up but only 10% of Decadron pts still had a headache. Something to consider to help prevent bounceback.
Earnshaw, S.R., et al, Stroke 37:2751, November 2006: Use of NovoSeven for the treatment of ICH. This is expensive stuff $10,000 for the large dose, $5000 for medium dose, $2500 for small dose. The most cost-effective dose was w/ the middle dose (80 mcg/kg). I'm still not sold on this medicine, but you'll be hearing more and more for different uses (trauma, etc).
Cooper, J., et al, Ann Emerg Med 48(4):459, October 2006: Clinical risk for assessing self-harm. Prior history of attempt, prior psych dx, current psych dx, or current use of benzo during this episode all are positive risk factors for completing suicide w/in 6 months. All 22 pts who completed suicide had one of these criteria.
Hennerici, M.G., et al, Lancet 368:1871, November 25, 2006: Placebo or Ancrod for pts w/ ischemic stroke. Ancrod is taken from pit vipers and helps decrease thrombus formation. Ancrod wasn't better than tPA, but coincidentally has performed better than tPA when you review results b/w different studies. Nothing new to take here.
Meurer, L.N., et al, Ann Fam Med 4(5):410, September/October 2006:
Earnshaw, S.R., et al, Stroke 37:2751, November 2006: Medical College of Wisconsin study that looked at all pts who had some sort of medical injury due to trx, error, etc. However when corrected for baseline mortality risk, the magnitude of error is much lower than previously stated.
Rossignol, J.F., et al, Aliment Pharm Ther 24(10):1423, November 2006: Use of Nitazoxanide for treatment of gastroenteritis. It shortens the course by one day. Nothing that we'd really use here or change treatment.
Bartlett, J.G., Ann Intern Med 145(10):758, November 21, 2006: C-diff is now the most common cause of diarrhea in the US (when identified). More virulent strains and complications now then in prior years. PPI's increase the risk. Fluoroquinolones and cephalosporins are the most common Abx that cause it.
Springhart, W.P., et al, J Endourol 20(10):713, October 2006: There was no difference in pts w/ renal colic b/w those who received no IVF or those who got large boluses. Interesting of note.
Turrentine, M.A., Obstet Gyn 107(2, Part 1):310, February 2006: Pts who were on Coumadin and took a one time dose of Diflucan had a 1/3 elevation of their INR. Only 6 patients and no significant bleed.
Shapiro, N., et al, Ann Emerg Med 48(5):583, November 2006: Patients with end-organ dysfunction do worse. However pts w/ SIRS didn't do worse. The bottom line is if you have shock, you're going to do worse.
Micek, S.T., et al, Crit Care Med 34(11):2707, November 2006: Before and after study of utilizing septic shock order sets in a hospital based on the Surviving Sepsis Campaign. 30 vs. 48% mortality and 3 days shorter time in the hospital. May simply be due to more aggressive IVF and early/appropriate Abx. Sponsored by the company that makes Xigris.
Tamir, E., et al, J Emerg Med 31(4):403, November 2006: For patients who are ambulating after MVC, do you need T/L/S spine xrays? No pts out of 1100 had a significant finding. Poor study, but probably not unrealistic.
Dalton, J.D., et al, Ann Emerg Med 48(5):615, November 2006: Randomized trial for adults w/ ankle sprains to Tylenol vs. Ibuprofen. There was no difference b/w the two groups.
Friedman, B.W., et al, J Emerg Med 31(4):365, November 2006: No change in pts receiving IM dose of corticosteroids for non-radicular LBP.
Tindall, A., et al, Emerg Med J 23:883, November 2006: Skin-wrinkle test for nerve injury in pediatric or non-cooperative pts. W/ autonomic nerve injury, they won't have wrinkles on their hand after wet. Nothing I'd use in the ED.
Bisset, L., et al, Br Med J 333:939, November 2006: Treatment of lateral epicondylitis (tennis elbow). Steroids work early but the effects change quickly and ultimately doesn't help.
Walsh, K.E., et al, Pediatrics 118(5):1872, November 2006: After implementation of computer order entry systems in pediatrics, 20% of errors were due to the computer system. Many studies show that they systems have lots of associated risks w/ them and while they may help w/ efficiency to a degree, there are lots of unintended consequences.
Psaty, B.M., et al, JAMA 295(23):2787, June 21, 2006: When doctors are involved in "seeding studies" (studies never meant to be published, but gain acceptance on formulary, pay the doc, get them to prescribe drugs, etc), not only do the docs involved, but their partners end up prescribing whatever pharmaceutical is involved.
Boyd, J.J., et al, Acta Anaesthesiol Scand 50(10):1266, November 2006: For heroin OD's who received pre-hospital narcan and signed out AMA, they had no adverse effects. If they're going to need narcan, they'll need it in the first hour. They state that if you follow a heroin OD for at least one hour and they do fine, they're safe for d/c.
Salo, D., et al, J Emerg Med 31(4):371, November 2006: RCT of continuous Alb SVN vs continuous Alb SVN + Atrovent for the trx of acute asthma. Adding atrovent really doesn't change anything in acute asthma (more beneficial in COPD). They were using 15 mg of Albuterol as part of the continuous trx.
Tsai, W.K., et al, Am J Emerg Med 24(7):795, November 2006: Pig-tail vs large-caliber chest tubes for spontaneous PTX. Use of the pig-tails is just as well and didn't cause significant problems down the line.
Cohen-Kerem, R., et al, Clin Ped 45:828, November 2006: OTC cold remedies for peds pts hasn't shown to be of benefit, but family docs love giving it and pediatricians as well (but not so much).
Turkcuer, I., et al, Am J Emerg Med 24(7):763, November 2006: Turkish study showing U/S is better than x-rays at finding wood or rubber FB in soft tissues. Since we have a SonoSite and 24 hr U/S, better to use that than the needless x-ray for non-metallic FB's.
Ott, M., et al, J Trauma 61(3):607, September 2006: Guess what, trauma pts get lots of radiation (probably more than we should). Try to be judicious when ordering x-rays, CT's, etc.

That's it...

A Little Goofy

2007-04-12T12:39:00.000-07:00

I found this case when reviewing my "interesting" case files. It has some interesting learning points...

CC: AMS
HPI: 23 yo M who has been progressively altered, ataxic and dropping objects the last 24 hours. + h/o OCD, depression, bipolar and anxiety d/o. Per his father (historian) he'll usually binge drink on a twice weekly basis in order to "curb" his OCD. Just yesterday he was arrested for a DUI. The patient has had some increasing stress as well due to an illness w/ his girlfriend. Per the father he takes Haldol, Klonopin, Depakote, Seroquel and Effexor. The patient is quite somnolent and is unable to provide a history. He'll open his eyes, mumble an incoherent response to the question or repeat the question itself and go back to sleep.

PMHx: OCD, depression, bipolar d/o, anxiety
Meds: Haldol, Klonopin, Depakote, Seroquel, Effexor
SHx: Binge EtOH abuse
ROS: Unable to obtain secondary to AMS

V/S: BP: 141/90 HR: 94 RR: 18 Temp: 99.6 Sats: 96% (RA)

PE: (pertinent findings)

Gen: Somnolent, but arousable. Will try to follow commands but just falls back asleep.

Neck: No meningismus; Negative Brudzinski's and Kernig's

Neuro: No focal CN deficits. MOE x 4, but not coordinated

Diagnostic Testing:

EKG: NSR @ rate of 94; no ectopy; nl QRS, QTc

WBC: 10.6 U/A: neg except for trace ketones

K+: 3.4 Cl: 97 BUN/Cr: 9/0.4 Glucose: 92

Tylenol: neg ASA: neg EtOH: neg UDS: neg

Depakote: 344 Ammonia: 143

Discussion:

Based on this patient's med list and the ataxic, uncoordinated like movements he had, I had a suspicion that he might be a depakote toxicity. Hence besides checking the depakote level, I had a ammonia level drawn. Ammonia can be elevated in patients with depakote toxicity and can contribute to the encephalopathy. Obviously Klonopin, Seroquel, Haldol, EtOH and drugs of abuse can also present with this picture. Given his EtOH abuse history and recent DUI that'd be something to consider, but he had no EtOH odor to him or quite honestly look like he was "just drunk".

After the depakote and ammonia levels came back, I discussed the case w/ toxicology and we started the patient on L-carnitine at 50 mg/kg IV over 5 minutes. A dose was repeated in five hours and a repeat depakote level was ordered in 4 hours. The patient was admitted to the ICU. Later his ammonia levels peaked at 233 and

Valproic acid toxicity:

Valproic acid elevated CNS GABA concentrations. It also prolongs the recovery of inactivated Na+ channels. Oral absorption is rapid (often within 1-4 hours), with peak plasma levels within 3-5 hours. At levels of 80 ug/mL 90% is protein bound, however, in the case of toxicity there is an increase in "free drug" causing a proportional increase in available drug after protein saturation. Elimination is based on first-order kinetics w/ a half-life of 7-15 hours. Therapeutic levels are b/w 50-100.

Valproic acid (depakote) can cause hepatic failure with days or up to two years after first use. Toxicity often results in AMS, lethargy, N/V, and ataxia. LFT's and ammonia levels can be elevated. AMS can be directly related to the elevated CNS GABA levels (like EtOH) or ammonia levels. Patients may have depressed DTR's and pinpoint pupils (mimicking opioids).

Treatment of valproic acid toxicity follows the usual tox guidelines of supportive care. Since it closely mimics opioids, give a test dose of Narcan is reasonable (as well as checking glucose, etc). Since absorption is rapid, charcoal is probably only efficacious if given in the first sixty minutes. Hemodialysis does decrease serum levels (remember it's protein bound) and can be used.

In this particular patient L-carnitine was administered. This treatment has been looked at by some jackasses named LoVecchio and Samaddar (L-carnitine was safely administered in the setting of valproate toxicity. LoVecchio F - Am J Emerg Med - 01-MAY-2005; 23(3): 321-2) and proven to be safe. I'll rip the study later on all its "flaws" but for now we'll accept the gospel according to Frank.

So if you have any interesting tox cases or Frank et al want to comment on this, fire away...

Herky Jerky

2007-04-12T09:34:00.000-07:00

From the case files of one of our colleagues...

CC: Seizure

HPI: 24 yo male presents s/p first-time seizure. Per his mother, she went to go pick him up for work. When he didn't answer, she broke down the door and found him actively seizing. He has no history of seizures. He had a traumatic MVC a year before. He has since recovered and been living w/ roomates. The only other history is that he's been coughing for the past few days.

PMHx: Traumatic MVC

Meds: Lexapro, Ativan

SHx: Lives with roomates

ROS: Unable to obtain

V/S: BP: 149/65 HR: 61 RR: 24 Temp: 97.9 (rectal) Sats: 97%

PE: (pertinent findings)

Patient is actively seizing with eyes deviated to the right. + Right facial twitching. No other pertinent findings on PE

Hospital Course:

The patient was given Ativan 2 mg IV to stop the seizures. Later he had mild spontaneous movement of his RUE/RLE. His LUE was "restless" and pulling at items. A CT scan was done using ketamine and the patient was loaded w/ cerebryx.

Labs:

WBC: 49.1 H/H: 17/51 BUN/Cr: 19/2.2 K: 2.8 CO2: 17

UDS: + THC Ammonia: 108

CT head: possible SDH in right posterior falx

CXR: possible "right-sided infiltrate"

LP was performed using ketamine. Results are as follows:

CSF WBC: 11,300 RBC: 3040 Polys: 85% Monos: 15%

The patient was loaded with Rocephin, Vancomycin and Acyclovir and transferred for neurosurgical evaluation.

Discussion:

This patient appeared to have had bacterial meningitis which resulted in seizures and altered mental status. Their CSF later grew out Strep pneumoniae. A couple of teaching points can be taken from this case.

A nice job by the doc involved to get the LP done in a difficult patient . Meningitis has to be considered in any patient with new seizures and/or mental status changes.

From an educational standpoint, perhaps ketamine isn't an ideal choice in this patient due to its side effects of increased ICP. Perhaps this patient had a traumatic GLF and suffered a epidural or SDH and hence the seizures. Propofol might be a better choice (especially w/ the lack of history or witnesses in what precipitated the seizures). Either way, avoid ketamine in patients who have or might have a traumatic brain injury. Also since radiology is calling a "possible" SDH, it would be wise to avoid anything that can bump up the ICP (especially when they're already seizing and probably causing a pretty good spike in their ICP already).

Also remember to give both your pediatric and adult patients a dose of steroids in suspected meningitis. They have been shown to decrease both adverse neurological events and mortality. Dexamethasone is the preferred agent and if you're going to LP, you can give a dose before you even put a needle in their back. Tis better to shoot first and ask questions later (as the departed Hunter S. Thompson would most assuredly agree with). Most regimens involve Dexamethasone 10 mg IV q 6 hours x 4 days ("Steroids in adults with acute bacterial meningitis: a systematic review": van de Beek D - Lancet Infect Dis - 01-MAR-2004; 4(3): 139-43.)

Another question that often arises is who can you LP without doing a CT to r/o space-occupying lesions? General rule of thumbs are that it's safe to LP prior to CT if they fulfil the following criteria: a) do not have new-onset seizures b) immunocompromised state c) signs that are suspicious for space-occupying lesions (papilloedema, focal neural signs) and d) moderate-to-severe impairment of consciousness. If they do not have any of these criteria, then you can safely LP the patient without head CT.

Also remember to give Ceftriaxone 2 g IV for suspected cases and consider the need for Vancomycin +/- Acyclovir as well.

Just a Quick Tug

2007-04-12T08:46:00.000-07:00

Here's another interesting case straight from the "classic" board questions series (that actually occur in real life)...

CC: H/A and speech change
HPI: 27 yo F presents w/ a headache and speech change. She had gone to her chiropractor earlier in the morning to get "adjusted". She felt fine afterwards and went home. Later she was at her OB's office when she began to have a H/A. After the appointment she went home and noticed that she had some aphasia and right-sided vision loss. All symptoms have since resolved and denies any current neuro deficits.
PMHx: Denies
Meds: Lexapro, HCTZ
SHx: Denies
PSHx: Denies

V/S: BP: 127/81 HR: 70 RR: 20 Temp: 98.3 Sats: 98% (RA)
PE: (Pertinent findings)
A&Ox4; Visual fields intact; No focal neuro defictis. Unremarkable exam

Initial Diagnositc Testing: Basic labs and beta HCG were negative. CT head was also negative.

Based on this history and symptoms, what would be of primary concern and what would you order?

A CT angiogram of the head and neck were ordered to r/o carotid artery. The patient did end up having a dissection of the proximal left ICA. She had patent intracranial vessels and intact posterior circulation. She was transferred to St. Joe's neurosurgical service for evaluation.

Discussion:
Although uncommon, cerebral artery dissection is an known adverse outcome of chiropractic manipulation. It can also occur spontaneously, after whiplash, neck-stretching, and in certain connective-tissue disorders (Ehlers-Danlos syndrome, Marfan syndrome, etc). It most commonly occurs in the extracranial carotid artery between C2 and the base of the skull.

Symptoms may include transient retinal ischemia, cerebral infarct, face and/or neck pain, Horner's syndrome, audible bruits and a pulsatile tinnitus.

Diagnostic imaging includes CTA or MRA to r/o dissection. Remember that CTA has a 1% complication risk.

Treatment includes neurosurgical evaluation. Heparin will sometimes be started to prevent thrombemboli, but I'd discuss it w/ your consultant before starting treatment.

So go out there and crack those necks...

Pain in the Belly

2007-04-12T07:24:00.000-07:00

Another case of mine that involves a relatively uncommon but significant diagnosis...

CC: Abdominal pain
HPI: 2 yo male presents w/ three day h/o abdominal pain. Patient has had an unremarkable PMHx, but for the last three days has had intermittent episodes of abdominal pain. Per parents he's been very fussy and irritable. He'll be fine and then seems to go over to the corner, get on fours "like a dog" and cry and grab his belly. Nothing seems to precipitate these events, they last for a couple minutes and then resolve on their own. He was seen in an UC three days earlier and had x-rays performed that were "negative". Parents were instructed that if symptoms persist, they should come to the ED.

He has no prior surgical history and still have normal BM's. Parents deny fevers, nausea/vomiting, travel, recent Abx use, GI hx, excessive weight loss, trauma, etc. No family h/o pyloric stenosis, but per parents, the UC doc informed them that if symptoms persist, then he should get an U/S. When the pain comes on he seems to grab at his epigastric/periumbilical region. Stools at the U/C were negative for fecal leuks, but parents admit to "foul-smelling" flatus.

PMHx: GERD as infant (no further trx)
Meds: Deny
SHx: Lives w/ parents and one sib
ROS: Negative except for HPI

V/S: HR: 79 RR: 22 Temp: 99.6 Sats: 98% (RA)
PE: (pertinent findings)
Gen: Non-toxic, but fussy and irritable.
Abd: Soft and NT, no obvious HSM. During the exam, he curled up and cried excessively w/ a tense, hard abdomen

Comments: This is a pretty classic presentation for what he ultimately was found to have. Two year old w/ intermittent episodes of crampy, inconsolable abdominal pain has to make you consider this diagnosis and order a specific test that can be both diagnostic and therapeutic...

In the mean time labs had been ordered and were relatively unremarkable.

Labs: WBC: 10.7 Polys: 44% Bands: 3%
Electrolytes, urine all unremarkable

So late on a Saturday night (when he presented), I bugged one of our dear radiologists to come in and perform a barium enema (their choice- the newer literature shows that air enema's can work just as well) to r/o intussusception.

If you've never seen a BE study performed, they can be painfully boring until you get to the end of it (as in this one). For the first 50 minutes, the general excitement was getting the patient adequately sedated enough to tolerate the test and lay still. But once the ileocecal junction was getting closed, the diagnosis was made. There it was found that the contrast would not pass and even more importantly, the bowel was not reducing. It appeared as if he had suffered from an non-reducible intussusception.

The patient was quickly transferred to PCH for surgical evaluation.

So let's review some of the key features of intussusception...

Remember, that it involves any part of the GI tract telescoping into another segment. It's the most common cause of bowel obstruction in children from 3 months - 5 years. Over 60% of the cases are diagnosed in the first year of life. There is a male:female predominance of 4:1.

There is a seasonal incidence after the viral season. Other causes include a Meckel's diverticulum, polyp, HSP, tumors or FB's. Ileocolic intussusception are the most common (as was the case in this child).

As the upper part of the bowel enters into the lower part, it brings along the mesentery. This causes venous engorgement. Later on bowel edema, bleeding and sloughing can produce the classic "currant-jelly stools". However, this is a late-finding and if found the patient is already extremely sick.

The classic story is a child from 6-18 months old who will be fine and then suddenly drop or ball up and be inconsolable. Vomiting is usually rare. If you're lucky, you might feel a "sausage-shaped mass" in the right quadrant during an attack, but again, these children are usually so inconsolable, that I wouldn't rely on this finding.

I've made this diagnosis probably 3 or 4 times in my career and every time it's strictly based on history. The examination is difficult at best. Imagine if your bowel was incarcerated as a two year old. Would you lay back and allow some doctor w/ cold hands to push on your belly? Hence, this is one of those diagnoses where history is extremely important. Usually the parents provide all the info. The story is pretty classic and if they're giving you this type of story, I will refuse to send the child home until some sort of definitive testing is done. These are not the type of cases you can send home and chalk it up to "colic" or a "virus". Just like in this child, if it was allowed to persist, he could of ended up w/ dead bowel and even worse. Therefore, like meningitis, if you consider the diagnosis, you probably have to do the test to rule it out.

With regards to diagnosis, our radiologists still prefer BE's. Air enemas have shown to be just as effective in diagnosis, less radiation and with better rates of successful reduction. Do not perform an enema on a patient with signs of peritonitis, perforation or hypovolemic shock. These patients should obviously go straight to the OR. Ileo-ileo intussusceptions are much more difficult to diagnose and reduce.

All patients who have had a successful reduction should be admitted for observation. Recurrence happens in 0.5-15% of patients. Even after laparatomy, recurrence rate can be 2-5%.

If you have any questions or comments let me know.

Case Reports

2007-04-09T03:01:00.000-07:00

Here's an interesting little case that I saw recently....

CC: Alcohol withdrawal

HPI: 54 yo WF presents w/ EtOH w/drawal. Last drink was 48 hours prior. + H/o w/drawal and a possible Sz in the past (unsure if due to DT's). Did later admit to having just a "swig" of listerine 24 hours PTA. Denies methanol, ethylene glycol, etc. No h/o DM

PMHx: Hypercholesterolemia; EtOH abuse

Meds: Denies

PSHx: Denies

SHx: + EtOH abuse; Denies drug use

FHx: DM

ROS: Pertinent for anxiety

V/S: BP: 149/61 HR: 96 RR: 20 Temp: 97.8 Sats: 96% RA

PE: Pertinent findings- tachy in low 100's, anxious, slightly tremulous; Slight epigastric TTP

Hospital Course:

Obviously EtOH w/drawal is number 1-3 on the DDx. I checked a CBC, CMP, lipase. I gave her some Ativan to prevent full-blown w/drawal, monitors, etc. Here's where it gets a little interesting....

Pertinent Labs:

Glucose: 224

H/H: 10.8/32.3

MCV: 100.5

BUN/Cr: 15/0.9

K: 5.0

Cl: 92

Lipase: 179

Bicarb: 9

AG: 41

So why would this patient, who is not diabetic, have such a large AG and profound acidosis? I asked again about co-ingestants (methanol, ethylene glycol, etc). She again adamantly denied these except for the "swig" of listerine 24 hours before. I went ahead and ordered a couple labs with the thought that she might have an interesting condition that I used to see back at the Copa. What would you order and what do you think this might be?

I ordered an ABG, serum acetone, Beta-hydroxybutyrate, lactate and here are the results...

ABG: pH: 7.158 pCO2: 26 pO2: 95 Bicarb: 8.9 Base Excess: -18.5

Acetone: 3+

B-hydroxybutyrate: 76.2 (normal 0-3)

Methanol: neg

Ethylene Glycol: neg

Lactate: 6.3 (Normal 0-2.2)

So what is the diagnosis?

I diagnosed this patient with Alcoholic ketoacidosis (AKA). In review AKA is due to a decrease in fatty acid oxidation in association with poor PO intake or recurrent emesis. There will be a significant increase in serum ketones, mildly elevated glucose, large gap, mild to moderate increase in lactate and a beta-hydroxybutyrate:lactate ratio of 5:1 to 10:1 (normal is 1:1). In this patient the lactate came back soon, but the BHB is a send-out lab (but w/ a ratio of 12:1 helps confirm the diagnosis).

AKA can be seen in first-time binge drinkers or chronic alcoholics. The general starvation results in a decrease in glycogen and insulin stores w/ an increase in catecholamines, glucagon, growth hormone and cortisol levels. Lipolysis and hepatic ketogenesis is stimulated resulting in ketoacidosis.

Of note, AKA typically happens after an acute DECREASE in EtOH consumption (like this patient). They will often show tachycardia, tachypnea, mild to moderate abdominal pain (as seen in this patient, NV, etc. The initial AG will be 21 but elevate later.

Also interestingly, pH may be normal or even alkalemic early in the course. A contraction metabolic alkalosis secondary to protracted N/V may obscure the acidosis.

You want to make sure you also rule out other causes of a metabolic acidosis (methanol, ethlylene glycol, isopropyl etc).

Treatment is symptomatic. Volume repletion and glucose are mainstays of therapy. Glucose will stimulate insulin production which helps alleviate the lipolysis and ketone formation. Insulin is of no proven benefit. Make sure you also evaluate patients for hypophosphatemia and hypomagnesemia (both often seen in alcoholics). You can give the usual thiamine, folate and MVI as well. The acidosis will usually clear within 24 hours.

Hope this was of some educational benefit. Now have a drink...

February Bites

2007-03-07T15:06:00.000-08:00

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.

January Nubbins

2007-02-09T15:14:00.000-08:00

Here are some January nubbins. Swish and spit as needed...

Roger, V.L., et al, Circulation 114:790, August 22, 2006: Basically a "redefinition" of MI's. Mayo study that considers an elevated troponin to be the deciding factor for MI's. Of note, the study only looked at pts w/ elevated trop's. What about MI's w/ elevated CK-Mb but normal trop's? That obviously affects the study. Patients w/ only an elevated troponin were "less sick". Only half of the patients were diagnosed w/ an AMI by their docs if they only had an elevated troponin.
Chase, M., et al, Acad Emerg Med 13(10):1034, October 2006: 80% of patients w/ active CP had normal EKG's or non-specific EKG findings, but were later diagnosed w/ an MI. No difference b/w patients w/ symptoms or currently asymptomatic.
Morris, A.C., et al, Heart 92:1333, September 2006: British study in pts w/ ED CP (TIMI study). 1 in 30 patients w/ a TIMI 1 score (low risk) had a significantly bad outcome. TIMI score is not effective in determining risk in patients for cardiac event, MI, etc. TIMI scores are just not of use.
Masoudi, F.A., et al, Circulation 114:1565, October 10, 2006: Compared an ED docs vs. 4 cardiologists reading of an EKG that eventually were an MI. HOWEVER, the cardiologists were not blinded and knew that they were patients who earlier were diagnosed as an MI. The ED docs did it in real time. 12% of patients were missed by the ED docs and thus didn't get ASA, etc. However, it was based on the doc's documentation but not necessarily given a form to ask their opinion. Doesn't portray ED docs in a good light, but a VERY fundamentally poorly structured study. They need to improve their methods significantly.
Lenderink, T., et al, Eur Hear J 27(15):1799, August 2006: Patients w/ ACS who were treated w/ statins in the first 24 hours did better w/ regards to mortality. However, if a patient is too sick they usually don't get statins pushed in the first 24 hours, while the patients who are not too sick get them w/ 24 hours. Sponsored by the drug company. Again, flawed methods. Other RCT's have shown no benefit.
Kearon, C., et al, JAMA 296(8):935, August 23-30, 2006: Randomized study of outpatient trx of DVT's w/ either lovenox of subQ heparin. Cost of standard heparin was $37 vs $712 for lovenox. Obviously a huge difference. No statistic difference in outcome of all important factors. Traditional thinking is you would use lovenox b/c it saved you inpatient costs. However, standard subQ heparin works just as well and is much cheaper. This is a very important study. Do we start patients on this now? I'd be interested in what you guys think.
Kaji, A.H., et al, Pediatrics 118(4):1493, October 2006: Use of Braslow tape in pre-hospital setting shows it's a not very good estimate of true weight and correct epi doses.
Barone, J.E., et al, J Trauma 61:468, August 2006: Is the Allen test necessary prior to radial artery puncture? They reviewed six studies w/ varying results. There have been no RCT's, it doesn't predict ischemia, you can't use it on pt's who can't do it, etc. It's neither accurate nor reliable. Nice to know.
Detsky, M.E., et al, JAMA 296(10):1274, September 13, 2006: If it looks like a migraine, it's probably going to be diagnosed as a migraine. Interesting logic.... Nothing from this study that answers any questions it's trying to ask- to headache patients all need a CT? Prior studies have shown there is no yield for a CT head in patients w/o any worrisome neuro sx's.
Doran, T., et al, N Engl J Med 355(4):375, July 27, 2006: British study about pay-for-performance. The strongest indicator for the best P4P was that they excluded patients b/c they "don't qualify" for any particular reason and get your bonus. Basically gaining the system by going through the checklist. Who will decide what the checklist will consist of? As long as you scheme and gain the system, you can meet the criteria. What happens if pharm companies gain influence w/ the committees and determine you have to give drug "X" to meet a criteria. In Britain, they had PCP's making up to an extra $40K a year (so obviously financial incentive to gain the system).
Cutler, D.M., et al, N Engl J Med 355(9):920, August 31, 2006: Harvard study looking at the medical costs on society and healthcare. Lot of flaws here.
Akkad, A., et al, Br Med J 333:528, September 2006: British study looking at consent forms. Patients frequently don't know what they're signing, the benefit of consent, etc. Not much surprise here.
Potts, M., et al, Br Med J 333:701, September 30, 2006: "Parachute" approach of evidence based medicine. Spoofs the thought that only RCT's are pristine and we've made several decisions based on observational studies. In conditions w/ high morbidity and mortality, you can't always wait for RCT's and balance all the benefits and costs of methods.
Lazare, A., JAMA 296(11):1401, September 20, 2006: Medical apologies are good in error. A little harsh in that he wants doctors to express "shame", etc. A little tough to consider shame when people make mistakes. It probably decreases the risk of legal action, but can't be sure.
Spiro, D.M., et al, JAMA 296(10):1235, September 13, 2006: Wait and see approach to acute OM in pediatrics. 40% of wait and see group got Abx. Not as much as you'd expect. Interesting thing was there was no difference in outcome b/w either group. Only side effect was more diarrhea in the grop who got Abx.
Khan, J., Emerg Med J 23:726, September 2006: What's the best approach for a floater(s)? They feel it's best to call ophtho at any time. High liability item. They rarely get called and the pt put the time into to come to the ED to be seen for it.
Stork, C.M., et al, Acad Emerg Med 13(10):1027, October 2006: Zofran worked better on peds N/V vs. dexamethasone (interesting trx).
May, G., Emerg Med J 23:722, September 2006: Best evidence study for the use of somatostatin in the control of UGIB non-variceal bleeds. Other studies have been mixed and not shown a benefit or decrease in mortality. Vasoconstrictors can cause ischemia and increase bleeding. Let GI decide...
Newman, D.H., et al, Ann Emerg Med 48(2):182, August 2006: Do you need to check an INR on every ED pt on coumadin? What if they have no clinical reason? I still take the conservative approach and check it. I've found abnormalities requiring admission w/o symptoms more than once. What if they had one checked one day before and it was normal?
Bottieau, E., et al, Arch Intern Med 166:1642, August 14-28, 2006: Any patient traveling from the tropics and have a fever should be checked for malaria. Most are non-faliparum. The one that will kill you is falciparum. Recurrent were ricketssia, malaria, dengue and typhoid.
Taylor, R.W., et al, Crit Care Med 34(9):2302, 2006: Blood transfusion in critical care pts and nosocomial infections. People who are sicker get more transfusions and are at increased risk for nosocomial ifx. 14% in those who got blood vs. 6% in those not transfused. Of course, patients getting blood are usually sicker. There seems to be an immunosuppression associated w/ those receiving blood.
Gallagher, T.H., et al, Arch Intern Med 166:1605, August 14-28, 2006: American vs. Canadian docs in admitting error. Malpractice environment doesn't seem to affect whether you disclose an error. 85% who disclosed an error were glad that they did.
Seehusen, D.A., et al, Br Med J 333:171, July 2006: Use of stirrups during a routine pelvic exam w/ speculum and bimanual. They preferred not to have the stirrups. On many exams you don't need a speculum and how often is it performed when we don't need to? Either way, I'll have to take their word that it's more comfortable w/o...
Coakley, G., et al, Rheumatology 45(8):1039, August 2006: When a patient presents w/ the first episode of a hot, red joint? What if it looks like gout? Some say to tap them, I don't think so. Of note, 30% who have gout have normal uric acid levels. Blood work isn't of any utility in gout.
Ong, A.W., et al, Am Surg 72:773, September 2006: Routine c-spine in alert, oriented geriatric patients after blunt trauma. A negative neuro exam, no c-spine TTP, no EtOH, etc. had x-rays and CT's. 3% ended up w/ an injury that required intervention. 8 of the 9 interventions involved a collar. This is taken from a chart review.
Antevil, J.L., et al, J Trauma 61:382, August 2006: The study suggests that CT c-spine be the intial study for trauma patients. The CT will find injuries that x-rays miss. The study has enough flaws that I'll keep my approach of x-ray first.
Beynnon, B.D., et al, Am J Sports Med 34(9):1401, September 2006: Randomized treatment to ankle sprains. The best treatment for mild sprain was ace wrap. The best thing a patient can do is early activity on the joint. The sooner they're back to activity, the better they do.
Norris, R.L., et al, Am J Emerg Med 24(5):618, September 2006: Case report of a med student who applied tube gauze to a finger that caused digital necrosis and amputation. How would you like to be that med stud?
Nieman, C.T., et al, Acad Emerg Med 13(10):1011, October 2006: A study looking at the use of Broslow tapes from the prestigious Case Western Reserve Univeristy (ahem). It's not very accurate and can cause under-dose of obese and larger infants/peds pts.
Cravero, J.P., et al, Pediatrics 118(3):1087, September 2006: Peds procedural sedation. 1.5% had desats. No significant outcomes, no deaths, etc. Only one aspiration. Just shows that it's a safe when done in the appropriate situation.
Salpeter, S.R., et al, J Gen Intern Med 21(10):1011, October 2006: Looked at anticholinergics vs. albuterol in COPD pts. For chronic use anticholinergics are of benefit.
Fortin, J.L., et al, Clin Toxicol 44(Suppl 1):37, 2006: Use of Hydroxocobalamin in the treatment of acute smoke inhalation. Not in the US- done in France. Anecdotal evidence is that it works.
Mangione-Smith, R., et al, Arch Ped Adol Med 160:945, September 2006: In pediatric patients we're more likely to prescribe Abx when we assume that the parents want them by asking if it may be dx "X" or question the plan.
Yoder, K.E., et al, Clin Ped 45:633, September 2006: No benefit in trx w/ steroids, benadryl or placebo for pediatric uri sx's and cough.
Sinha, M., et al, Pediatrics 117(4):1162, April 2006: From the copa- distracting peds pts during lac repairs is of benefit.
Vaillancourt, C., et al, Can J Emerg Med 6(3):147, May 2004: In acute compartment syndrome, how long before muscle necrosis. Some as quickly as 3 hours. Quite variable in time to injury and times. Bottom line is muscle can die early on and you can't miss this dx.

Educational Tips

2007-01-23T15:01:00.000-08:00

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

2007-01-23T12:34:00.000-08:00

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.

November Abstracts

2006-12-07T14:38:00.000-08:00

Here are your November abstracts- enjoy with your favorite nog...
Capraro, A.J., et al, Ped Emerg Care 22(7):480, July 2006: A study reviewing pediatric trauma patients and the routine labs ordered. There were no tests that were sensitive or specific. Bottom line is that they are not of benefit as a routine screening test.
Garcia, M.J., et al, JAMA 296(4):403, July 26, 2006: An interesting study that looked at the use of the new 64 slice CT scanners to evaluated CAD in ACS pts. The general thought are that these CT's will become the new screening tools and prevent needless angios. Or in CP pts in the ED, we'd CT them and if they had a low score, go home. In this study, if the pt had a high calcium score, they'd just go to angio. Of note, pts undergoing this test must lay perfectly still as any motion will cause difficulty in reading the tests. The bottom line is that the sensitivity was only 75% and specificity was only 79%. Ergo, there will be a lot of false positives. Why does this matter? Well consider this akin to the D-dimer. In theory, we should be doing these tests to r/o the low-risk pts. However, in the no-risk pts you'll do this CT and get a false positive result. Then you take them off for an unnecessary angio. Hence the problem with these tests so far. Until the technology improves, a test that's supposed to save people from angios could possibly cause needless angios to be performed. Interesting to note...
Mitchell, A.M., et al, Acad Emerg Med 13(7):803, July 2006: A new set of cardiac markers to r/o low-risk ACS. They all did worse than our current measures (and the authors agree). They included CRP, BNP, myeloperoxidase and one other lab.
Bhangoo, P., Emerg Med J 23:568, July 2006: A chart review of cocaine chest pain and trx options. The bottom line is that if they have CNS effects primarily use benzos. NTG works just as well in relieving CP. Also remember not to use B-blockers to prevent unopposed alpha-blockade (use phentolamine).
van 't Hoff, A.W.J., et al, Am Heart J 151:1255.e1, June 2006: A freaky-deaky Dutch study that examined pre-hospital dx of AMI in order to expedite PCI. Those who were dx'd pre-hospital made a significant change in mortality (10% vs 3%) but these numbers are suspicious and probably some confounding factors. This also wasn't a randomized study.
Ortolani, P., et al, Eur Heart J 27(13):1550, July 2006: An Italian study that again looks at direct referral to PCI from home based on early dx. They had relatively long door-needle times w/ average 90 minute drive times. There was no significant change in mortality in any of the different groups.
Bozeman, W.P., et al, Resuscitation 69:399, June 2006: A study you might be hearing about in the future. They looked at pts with arrest and failing resuscitative efforts (on average failed 8 rounds of meds). They were given an empiric dose of TNKase. 25% of these pts had spontaneous return of circulation and two walked about of the hospital later. Obviously this med would be for either AMI or PE. Also the question is whether spontaneous return of circulation translates into pts being neurologically intact and eventually walking out the door. Probably future studies will be done (especially since it's still on patent).
Holzer, M., et al, Stroke 37:1792, July 2006: An interesting Austrian study that utilizes induced hypothermia in witnessed cardiac arrest and remained comotose. They utilize the same technique that the "cool MI" study does (garden hose in the IVC to induce hypothermia). Either way pts who received this trx did significantly better. The 30 day survival rate was 69% vs 50% (control). Average time to 33 deg celsius was 4 hours (quite a delay). But neuro outcome again was 53% vs 34%. These are similar results to other studies. Cold is the way to go...
Oddo, M., et al, Crit Care Med 34(7):1865, July 2006: Another study looking at induced hypothermia again after cardiac arrest. Again they did better and they have low numbers needed to treat.
Cucchiara, B.L., et al, Stroke 37:1710, July 2006: A study that examined a risk stratification system for TIA's and future CVA's. They utilized the ABCD system. A(ge) B(lood pressure) C(linical features) D(uration of sx's). There is an association with these variables, but in this study only two pts went on to have a CVA (a very lower number). Ergo, they have such a low "N" that you can't really take much info from this or say it's a good study. Until proven otherwise, they're high-risk for a CVA and it's best to admit them and put them through the work-up (if they haven't already).
Dubinsky, R., et al, Neurology 66:1742, June 2006: A Nationwide CVA chart review. This again supports the following important info: only 1.2% of all pts with CVA's get tPA. Patients receiving tPA had a higher mortality rate (8.7% vs. 5.8%). Also patients receiving tPA. Patients receiving tPA had 10x higher rates of bleeds (4.2% vs. 0.4%). However, you're much more likely to be sued if you DON'T give tPA (for negligence). Stay tuned for more. But again, patients seem to do worse if they get tPA.
Mangurten, J., et al, J Emerg Nursing 32(3):225, June 2006: In brief, bring family members in during peds resuscitative efforts. Family members feel that they can see everything being done and preferred being there.
Fuda, K.K., et al, Ann Emerg Med 48(1):9, July 2006: A Massachusetts data set that showed that only 1% of all state patients visit the ED greater than 5x a year (considered frequent flyers). However this 1% accounted for 18% of all ED visits. This astounding number is similar to another study. This is interesting if you look at the reasons for the visits (true medical reasons or perhaps pain control?).
Styrud, J., et al, World J Surgery 30(6):1033, June 2006: A Swedish study that randomized probable cases of acute appendicitis w/o perf into either a) OR or b) IV Abx with surgery if they need it. 75% of the IV Abx group didn't have surgery and didn't have a recurrence of appendicitis. Interesting to note, but I don't see this changing the culture of trx of appy's in the US.
Mazaki, T., et al, Br J Surg 93(6):674, June 2006: A hot-button topic in the Barrali household- IV abx don't seem to change the outcome of acute necrotizing pancreatitis. A very small sample size.
Poehling, K.A., et al, N Engl J Med 355(1):31, July 6, 2006: Consider the flu in pediatric fevers. Do a simple swab and if positive, you have your answer and won't have to give Abx (and may be able to trx w/ the flu meds if caught early enough).
Poehling, K.A., et al, Arch Ped Adol Med 160:713, July 2006: Another flu study. 99% positive results were influenza A.
Hannafin, B., et al, Am J Emerg Med 24:487, July 2006: A study from the infamous Maricopa ED (of note the lead author is an applicant)- looking at administration of Rhogam to 1st trimester pregnant females undergoing SAB. All of our info is based on one trial in 1972 (I smell LoVecchio all over this one). The bottom line is there isn't really any evidence to support the claim. The thought is the cost/benefit is so high (hydrops fetalis) that a benign intervention should be continued (for fear of missing out on one). Doesn't make it right, but CYA medicine.
Knight, J.R., et al, Am J Emerg Med 24:423, July 2006: A study that reviewed calcaneal fx's and the use of Boehler's angle. I know Daniels calculates it on all his foot films. Bottom line: look at the trabeculae and if you're concerned and the plain film x-ray is negative, get a CT.
Mohr, B., Can J Emerg Med 8(4):247, July 2006: I haven't seen a Bier block used in the ED for about five years, but they looked at it for trx of wrist fx. Bier blocks consistently do better than hematoma blocks. However, w/ procedural sedation available, it's kind of a moot point.
Hendey, G.W., et al, J Emerg Med 31(1):23, July 2006: If someone has had prior shoulder dislocations and they didn't have trauma, you don't need a PRE OR POST reduction x-rays. Just reduce and send home as they have no trauma or complicating factors. It's nice to know, but I have a feeling that we'll still do it to prove there's no Hill-Sachs fx, etc.
Hampers, L.C., et al, Ped Emerg Care 22(7):465, July 2006: In simple febrile sz's you don't need to do any tests or w/u. Thus they looked at to see what tests the docs actually did- we did too many tests and work-ups. 5% got an LP, 11% had head CT, etc.
Merenstein, D., et al, Arch Ped Adol Med 160:707, July 2006: Infant response to benadryl 1 mg/kg for sleepless children. No difference b/w the trx group and placebo. Interesting to note.
Temple, A.R., et al, Clin Ther 28(2):222, February 2006: They compared tylenol (up to 4g qd) to naproxyn for trx of OA in older pts. Pts did just as well and had no lab abnormalities. This is opposed to the next study...
Watkins, P.B., et al, JAMA 296(1):87, July 5, 2006: They examined the results of taking 4g of tylenol qd and the effects on AST. They said 35-40% of tylenol receiving pts had a bump in their LFT's up to 3x normal. These were younger and healthier pts. So these two studies differ in their results. The second study was made by the manufacturer of the opioid compared to tylenol- so go figure...
Bijur, P.E., et al, J Pain 7(6):438, June 2006: MD understanding of pain by pts w/ long-bone fx's. Presence of fx matter more than pt's complaints of pain.
Gislason, G.H., et al, Circulation 113:2906, June 27, 2006: Another study showing COX-2 inhibitors increase risk of MI. Not a randomized control trial, but just more fuel for the fire.
Aggarwal, P., et al, Emerg Med J 23(5):358, May 2006: Nebulized Mag doesn't help in acute asthma exacerbation.
Harnden, A., et al, Br Med J 333:174, July 22, 2006: Consider pertussis in the persistent cough in the pediatric pt. Of pt's w/ a persistent cough, 1/3 unded up having pertussis on their titers. They usually have post-tussive emesis, copious sputum and paroxysms of cough.
Ramanujam, P., et al, Acad Emerg Med 13(7):740, July 2006: Something that we all know but is a thorn in our side (may want to forward to CHW HQ)- BLOOD CX'S DO NOT CHANGE THE MANAGEMENT OR OUTCOME OF PT'S ADMITTED W/ COMMUNITY-ACQUIRED PNEUMONIA.
Metersky, M.L., et al, Chest 130(1):16, July 2006: Does administering Abx w/in 4 hours of presentation of CAP matter? Often there will be atypical presentations thus docs give it to everybody for fear of missing the 4 hour window, etc. Sound familiar?
Sparrow, A., et al, Arch Dis Child 91:580, July 2006: In the trx of croup, they examined the use of decadron vs. methylprednisolone (orapred, etc). The bottom line, is decadron lasts longer and thus you only have to give it as a one time dose. Orapred, etc. requires repeated dosing. Hence our use of decadron.
Linder, J.A., et al, Arch Intern Med 166:1374, July 10, 20: Evaluation of pharyngitis- bottom line is people will sometimes follow the guidelines for dx, but still end up giving the Abx.

that's it- enjoy...

October Abstracts

2006-11-12T14:44:00.000-08:00

McNamara, R.L., et al, J Am Coll Card 47(11):2180, June 6, 2006: Median door-to-balloon time was 102 minutes. They demonstrated a direct correlation b/w door-balloon time and outcome. Mortality went up with every 30 minutes increments. However, this was not a randomized study and all CP's started within 6 hours.
Daniels, L.B., et al, Am Heart J 151:999, May 2006: They looked at the direct correlation b/w BNP and obesity. BMI is inversely related, so you need a lower-cut off for obese individuals. Nice oh by the way, but nothing that changes my practice.
Murray, H., et al, Can J Emerg Med 8(4):251, July 2006: The use of BNP in the evaluation of acute dyspnea in the ED. First of all there's no difference b/w BNP and pro-BNP. Different cut-off values, but essentially the same test. They performed a retrospective chart review testing the efficacy of BNP in dx'ing CHF. The bottom line is BNP will overcall CHF and your clinical skills will be just as good (if not better) as the BNP test. If you think it's CHF, it's going to be CHF and the test won't help. BNP is only sometimes useful in patients who you're not sure and only then it MIGHT help. I really never order this test anymore unless someone else wants the results.
Battaglia, M., et al, Arch Intern Med 166:1073, May 22, 2006: A meta-analysis again looking at BNP in the dx of CHF. It's only 80% accurate as a test. If you're going to treat a pt as if they have CHF, don't bother w/ getting the test. Especially if you're going to treat them the same way regardless of the results.
Singer, A.J., et al, Acad Emerg Med 13(6):623, June 2006: They used a laser to help pretreat skin before IV cannulation in adult and peds. This "laser" (attached to ill-tempered sea bass) seems to work.
Hallstrom, A., et al, JAMA 295(22):2620, June 14, 2006: Studied the difference b/w manual CPR and a device that provides mechanical piston compressions. They actually showed that it was worse vs. manual CPR and they stopped the study early. Another study showed a positive effect w/ the device.
Pizon, A.F., et al, J Emerg Med 30(4):367, May 2006: A chart review looking at meningitis over the last 10 years. The classic triad wasn't there frequently. Be careful of post-up NSG patients. Nothing horribly exciting from the study. It's becoming more uncommon in immunocompetant pts.
Hoffman, J.R., Emerg Med Australasia 18(3):215, June 2006: An editorial looking at the use of thrombolytics in ischemic CVA. There have been malpractice suits against docs for NOT giving tPA. Of course the medical research hasn't shown a benefit, but actually worse outcomes when given. There may eventually be legislation forcing "stroke centers" to give tPA or not be deemed as such. The bottom line is that there isn't any good evidence that it shows benefit. It probably does more harm than good.
Willmot, M., et al, Hypertension 47:1209, June 2006: Transdermal glyceryl trinitrate lowers BP, but didn't affect outcomes in acute ischemic or hemorrhagic CVA. A small study and they didn't measure CPP. Nothing here that would change your management.
Birbeck, G.L., et al, Neurology 66:1527, May 2006: They looked at the effect of a stroke team at specialty hospitals/centers. Number needed to treat was 1 for every 50. Having a stroke team might not do anything except making sure they receive the appropriate treatment under the correct circumstances. This was a survey however.
Banks, J., et al, JAMA 295(17):2037, May 3, 2006: An oh-by-the-way study, but we spend more than twice on health care per person in the US vs. England, however, over all socioeconomic classes, we have much sicker people. Even though we have lower smoking rates, etc. the US does worse on all levels.
Garbutt, J., et al, Pediatrics 117(6):e1087, June 2006: If you're going to trx peds AOM w/ Abx, regular dose Amox 45 mg/kg/d (not high-dose) unless you have a very good reason.
Manes, G., et al, Am J Gastroenterol 101(6):1348, June 2006: An Italian study that looked at early, prophylatic Abx in the management of acute pancreatitis. There were no differences in major outcomes (death, sepsis, etc).
Kennedy, K.P., et al, Br J Urol 97(5):903, May 2006: Dietary tips for prevention of kidney stones. PO hydration is the biggest factor (drink lots). Decreasing calcium doesn't change anything. Unless you're eating large amounts of oxalate foods, it shouldn't make a difference.
Huttner, H.B., et al, Stroke 37:1465, June 2006: A small chart review that at prothrombin complex concentrates (PCCS) vs. Vit K or FFP in acute intracranial hemorrhage. Outcomes were poor in all groups. There didn't show a benefit in any group.
Kumar, A., et al, Crit Care Med 34(6):1589, June 2006: Shortening the time of Abx in septic patients (thus by definition hypotensive). The survival decreased by 7.6% with each hour that passed in delay to Abx. Nothing horribly surprising.
Cooper, W.O., et al, N Engl J Med 354(23):2443, June 8, 2006: The use of ACE inhibitors during the first trimester of pregnant females. There was a three-fold increase in CNS and cardiac abnormalities. Thus if it's a female who may be or is pregnant, get them off ACE inhibitors.
Caird, M.S., et al, J Bone Joint Surg 88A(6):1251, June 2006: A decision tree in determining toxic synovitis vs. septic arthritis in peds hips. What's interesting is that 17.5% that had none of the criteria had septic arthritis. If in doubt, tap the joint.
Rivero-Arias, O., et al, Spine 31(12):1381, May 20, 2006: PT didn't change outcome in LBP (simple musculo-skeletal) strain.
Mularski, R.A., et al, J Gen Intern Med 21(6):607, June 2006: Using the pain scale as a "5th" vital sign didn't change outcome. People would still be hurting and they'd document the pain scale, but meds didn't come aflowin'...
Heres, S., et al, Am J Psych 163(2):185, February 2006: A startling (sarcasm) study that showed that drug company sponsored studies may not depict accurate results, cause bias, etc.
Kim, M.K., et al, Ped Emerg Care 22(6):397, June 2006: They looked at vomiting of corticosteroids during an asthma exacerbation. 17.7% blew chunks after generic prednisolone vs. 5.4% w/ Orapred.
Putland, M., et al, Ann Emerg Med 47(6):559, June 2006: Chart review looking at adverse effects of IV epi for asthma exacerbation. Major adverse effects in 3.5% but no long term consequences (maybe just b/c they were sick asthmatics). Still use it w/ caution and be wary of possible effects.
Levitan, R.M., et al, Ann Emerg Med 27(6):548, June 2006: Laryngeal view during intubation using BURP (Back, up, right) technique vs. Sellick maneuver vs. bimanual laryngoscopy. Bimanual was the best for getting glottic view. This means you have the scope in your let hand and you move the cartilage yourself w/ your right hand, once you find the spot have an assistant hold it in position.
Stein, P.D., et al, N Engl J Med 354(22):2317, June 1, 2006: The use of a multi-slice CT scanner is better at finding a PE than single-slice CT scanners. CT venograms can miss up to 14% of PE's. If the CT chest is negative and you have a high-index of suspicion, get the duplex LE U/S as well looking for DVT.
Matthews, S., Br J Radiology 79:441, May 2006: Use of CT chest to r/o PE in pregnant females. V/Q scans have higher radiation to the fetus than a CT chest. Bottom line is if you need to evaluate for PE, get the CT chest. Better that mom gets the radiation than the fetus.
Martin, D.R., et al, Lancet 367:1712, May 27, 2006: You get 10-20 mSv of radiation with each CT. This translates into a risk for leukemia or lymphoma in 1 in a 1000 due to the radiation. Other estimates have it at 1:2000. Either way, some stats for your patients and your own edification.

I'm feeling phlegmy...

2006-10-24T03:48:00.000-07:00

Here's an interesting case that I just had making a "sexy diagnosis" (at least to pin-heads like myself and "the little ball of hate" aka Evan)...

CC: "Leg Swelling"
HPI: 39 yo caucasian male presents w/ RLE pain. Significant h/o recent dx of RLE DVT (per pt appeared to be isolated to the popliteal region). While admitted he was also dx'd w/ B/L pulmonary embolism. Pt has been on Coumadin, but has not had it checked since his discharge from the hospital (one week prior). He has chronic SOB (secondary to morbid obesity and tobacco abuse). No new CP or SOB.

Patient primarily complains of new RLE pain and it being cyanotic. This acutely (per pt) started around 6 hours PTA. Now he has significant pain w/ any ROM of the leg, it's entirely purple and swollen. No new trauma to the area. The swelling now encompasses the entire RLE (where it was isolated to the popliteal region originally).

PMHx: DM, PE, RLE DVT, morbid obesity, CAD
Meds: Coumadin, oxycodone, Glucophage, nitroglycerin, Aleve
PSHx: Cardiac cath
SHx: Married
ROS: As above, otherwise nothing significant
V/S: BP: 145/86, pulse 95, RR: 20, Temp: 97.9 degrees, Sats: 98%
PE: Obese male on a gourney in quite a bit of discomfort, nontoxic.
Pertinent findings: Mottled w/ cyanotic changes to the entire, edematous RLE. Exquisitely TTP everywhere through the entire RLE. +2 DP/PT, but even this causes significant pain. No other significant PE findings.

So with this history and presentation, what sexy diagnosis came to my mind?

Possible Dx: Phlegmasia cerulea dolens

Phlegmasia cerulea dolens is a massive iliofemoral deep venous thrombosis. In this patient I was concerned about his lack of f/u on his INR and presumed that he was subtherapeutic. This could lead to propogation of the DVT. If allowed, this condition can cause arterial compromise and a compartment syndrome type picture (one that was becoming evident on exam). Remember, that with compartment syndrome, loss of arterial pulses is a LATE finding (too late). So while he has palpable pulses, this acute, edematous, cyanotic leg is consistent with this diagnosis. If pulses are lost the leg becomes doughy white and pallorous - this is referred as phelgmasia cerluea albans.

So as I left the room, I placed a call to vascular surgery stat. Spoke w/ the surgeon on call and I was able to get interventional radiology to come in w/ the vascular surgeon in order to perform a thrombectomy. The patient was about six hours into the event and was at risk for limb ischemia. As it happened, the patient's INR was 1.08 and he had been evaluated for hypercoagulable state.

Other possibilities in the DDx would be aortic dissection.

The patient went to IR, the thrombectomy was performed and he went to the ICU on heparin. Currently the patient is still admitted and now has a pink, only mildly edematous leg.

Hope this was of educational value.

September Abstracts

2006-10-23T15:15:00.000-07:00

Here are the September abstracts. Sorry about the delay- had some technical difficulties and my computer crashed. I guess i'm a Mac man now. For any of you who use Mac's, feel free to educate me. I'm sure I'm not utilizing most of its utilities and features. Ok, now on to the abstracts...

- Bare, M., et al, Internat J Technol Assess Health Care 22(2):242, April 2006: A retrospective Spanish study looking at intra-abdominal infections and the choice of Abx utilized initially. First off numbers weren't statistically significant. Also there were a lot of variables (co-morbidities), poor methods section w/ no info and poor chart review. Overall, nothing that would change your management and a flawed study.
- Steele, R., et al, Can J Emerg Med 8(3):164, May 200: The use of NTG in CP (not obvious AMI) with regards to pain relief- does this help you diagnose ACS? The answer is no. 2/3 of the people, regardless of the ultimate dx, had pain relief w/ NTG. Therefore, do not bother using pain relief or lack thereof in distinguishing ACS.
- Sen, A., et al, Emerg Med J 23:401, May 2006: Very few studies (two) have examined the utilization fo Beta-blockers in cocaine CP. Remember, that that's traditionally a "no-no" for concern of un-blocked Alpha-adrenergic activity. I was taught to use benzos and phentolamine (if needed) for alpha-blockade in cocaine CP. Only two human studies before. The studies that were done were in patients undergoing aniograms w/ known CAD. They were administered cocaine in the cath lab (not sure which IRB went for that). Alpha blockade, NTG, etc helped w/ the measurements. Howevever, when the pt was given B-blockers their cath numbers worsened (but no clinical events). The bottom line is do not use B-blockers in cocaine CP. Versed or ativan if needed and if they require it then use phentolamine. If you use B-blockers and have a bad outcome, you won't have any support from the literature.
- Briel, M., et al, JAMA 295(17):2046, May 3, 2006: They looked at the early use of statins in ACS. There is no statistical effect even if you delay up to 14 days.
- Bjorklund, E., et al, Eur Heart J 27(10):1146, May 2006: Swedish study looking at pre-hospital EKG and pre-hospital thrombolytics vs in-hospital PCI. However, pre-hospital patients were less sick and did do better. However, better studies have shown that even if there's a delay up to two hours in randomized patients, PCI is better.
- Ray, P., et al, Am J Emerg Med 24:313, May 2006: The use of ELISA D-dimer in the exclusion of DVT. Poor sensitivity (78%) and there were still DVT's missed by negative D-dimer. Again, only use a D-dimer in low-prob patient. There is no point in an intermediate or high prob patient. A negative D-dimer doesn't give you any comfort. You must get the Duplex U/S AND CT chest in these patients.
- Imberti, D., et al, J Thromb Hemost 4:1037, May 2006: A paper that looked at the use of lovenox in patients with suspected DVT prior to them receiving their duplex U/S. This doesn't affect us as much b/c we can get the U/S 24 hours. You can delay treatment if you can't get the U/S immediately in a suspected duplex U/S. There were no complications (death, etc) if you delayed the work-up 12 hours later.
- van der Hooft, C.S., et al, Arch Intern Med 165:1016, May 8, 2006: The use of corticosteroids and the possible risk of developing A-fib. Those w/ new A-fib had a 6x more common chance of being on high-dose steroids (their high dose was only 7mg a day of prednisone, so actually a small dose). This wasn't randomized, however, something interesting to note and look at in your patients w/ new A-fib.
- Ohlmann, P., et al, Crit Care Med 34(5):1358, May 2006: The use of d-dimer to dx aortic dissection. Patients with aortic dissection have elevated d-dimers. 99% sensitive, 34% specific. I don't think this changes my management. I'm going to order the CT and not order the d-dimer.
- Bailey, P.L., et al, Anesth Analg 102:1327, May 2006: The use of the central landmark approach in right IJ venous cannulation. The use of the SCM triangle, ipsilateral nipple, etc (traditional approach) is the central landmark approach. They used an U/S probe instead of a needle to see what the success would have been. The bottom line is if you're going to use this approach and miss, it's better to redirect laterally (vs. medially).
- Quinn, J., et al, Ann Emerg Med 47(5):448, May 2006: Examines the San Francisco syncope rule to identify pts w/ high-risk events. By a rule, they have to have a negative ED work-up. The factors are h/o CHF, HCT <> 30 and age > 50. The more predictors you had, the greater the probability that it was an UGIB (92-93% w/ 2-3 factors).
- Murphy, F.L., et al, Ped Surg Int 22(5):413, May 2006: A study where they took all acute pediatric scrotums (the name of my next band) to the OR. 1/4 had torsion, the rest were benign (torsed appendage, etc). The felt that it was better to go straight to the OR and bypass the U/S, etc. I can't imagine that peds urologists will ever go for this. They'll want the U/S, especially given the likelihood that it isn't torsion.
- Lankiewicz, M.W., et al, J Thromb Haemost 4(5):967, May 2006: Acute reversal of warfarin-induced coagulopathy with prothrombin complex concentrate. They didn't compare it w/ FFP. There's nothing here that would change your management.
- Leonhardt, G., et al, J Thromb Thrombolysis 21(3):271, June 2006: 28 German pregnant woman who received thrombolytics. 18 of 28 had normal pregnancies.
-Webster, A.P., et al, Emerg Med J 23:354, May 2006: British study identifying pediatric wrist fx's. Who cares? You're going to get the x-ray b/c none of us want to miss one and it's easy.
- Sard, B., et al, Ped Emerg Care 22(5):295, May 2006: Pediatric blood cxs. 3.5% had bacterial growth, but 80% were contaminant. Only 1% had positive cultures. The bottom line is most positive cultures are false positive, so why do the test now that we have pneumococcal vaccine? Another study shows that of the 1% who had a positive blood cx, none were pneumoccocus.
- Hsiao, A.L., et al, Pediatrics 117(5):1695, May 2006: Two-six month children w/ acute febrile illness. Again almost all kids had negative blood cultures (0.9%). 10% had positive urine cx's. Several false positive urine cx's (had positive viral test, OM, etc). Between these two studies, I still don't see us changing our practice until community standards change (and pediatricians). Just be aware of the low likelihood of positive blood cx (about 1%) and that many of the usual algorithms (Rochester criteria, etc) will eventually become moot b/c they were created to find bacteremia. If bacteremia is so rare now due to vaccines, do we need to implement these protocols? WBC count don't assist in the treatment. Blood cx are rarely positive and quite a few urine cx are contaminants as well. If the kid is sick, Abx and admit.
- Erlewyn-Lajeunesse, M.D.S., et al, Arch Dis Child 91:414, May 2006: Combined tylenol (15 mg/kg) + ibuprofen (5 mg/kg) in trx of pediatric fever. There was no additional benefit by giving them concominantly.
- Bar-Meir, E., et al, Plast Reconstr Surg 117(5):1571, April 15, 2006: Use of nitrous while plastic surgeons repaired pediatric facial lacs. Significant pain decrease. You might as well just use procedural sedation vs. brutaine.
- Nowak, R., et al, Am J Emerg Med 24:259, May 2006: Use of xopenex vs. albuterol in acute asthma exac. A lot of data mining (drug study sponsored). The bottom line, is there still shows no benefit of xopenex vs. albuterol.
- Sohne, M., et al, J Thromb Hemost 4:1042, 2006: A good study that shows that a sensitive d-dimer test INCREASES testing for PE, but NO INCREASE in diagnosing PE. This shows why a d-dimer is not a good test, because you ending up doing more tests without finding more cases. In a low-risk patient, a d-dimer is ok. Don't bother doing it in the no-risk patient, because if it's elevated, you then CT needless patients with no dz, but an elevated d-dimer (due to other factors). In a no-risk patient, don't check. In a low-risk, use it. All others, don't bother.
- Rodriguez, R.M., et al, Ann Emerg Med 47(5):415, May 2006: Use of CXR in blunt chest trauma. Sats < 90% on RA (100% sensitive, but 15% specific). The bottom line, is clinical judgment is still your best tool.
- Heal, C., et al, Br Med J 332:1053, May 2006: Can sutures get wet? Standard care being keep it dry for 48 hours vs within 12 hours. No difference in outcome b/w the two. Not a well-structured study and had a 8% infection rate in both (pretty high- ED standards is 5%).
- Salim, A., et al, Arch Surg 141:468, May 2006: The authors recommend whole-body scanning in trauma (head, neck, chest, abd/pelvis) in stable blunt-trauma pt. They had liberal use of who got the scans. Some had no evidence of visible trauma and still got all these tests. A poor study (for example they didn't even both checking the c-spine, they just CT'd them). Nothing that would change your management.
- Green, S.M., Ann Emerg Med 47(5):405, May 2006: Routine need of trauma surgeon on arrival of trauma pts. This was before ED docs were well trained or unable to manage life-threatening injuries, diagnostic modalities, etc. The need for a surgeon to be there is probably outdated.

That's it.

Trigger Point Injections

2006-09-11T19:23:00.000-07:00

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

2006-09-04T17:58:00.000-07:00

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...

July Abstracts

2006-08-22T17:07:00.000-07:00

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.

Interesting Case

2006-08-17T10:53:00.000-07:00

Here's an interesting, quick-hitter of a case to review from another doc...

3 yo male presents s/p first-ever sz
Generalized tonic-clonic sz for 5 minutes
No fever prior or after
No significant PMHx
No trauma or meds (was at daycare) and it was witnessed.
PE: AF, VSS
Pertinent findings:
Pt w/ his gaze towards the right without regard for anything in his left visual field
LUE/LLE paralysis
+ Babinski on left
Pt fussy and crying
All other findings unremarkable

DDx:

Obviously mass or space occupying brain lesion would be a consideration
Meningitis/encephalitis possible (not febrile and not acting ill before hand but you have to consider it)
SAH
It should not be a vertebrobasilar dissection based on neuroanatomy

Trx:

Pt was maintaining his airway and RSI held
The doc appropriately (in my mind) gave an initial dose of decadron (for either encephalitis, meningitis or neuroedema)
Stat CT head
Labs (usual)
LP

Results:

CT head negative
Labs unremarkable
LP: 100 RBC, 5 WBC

Course:

Pt's course showed gradual improvement (not completely) of paralysis and neuro deficits
Pt was transferred to PCH (just done yesterday so final dx pending)
My thoughts on this case is that the doc did everything appropriately. I bet the final diagnosis is...

Todd Paralysis

S/p seizure activity
It consists of focal or unilateral paralysis or neuro deficit after seizure activity, lasting up to 48 hours.
There is no specific treatment for it (just to r/o other specific causes)
Sx's resolve on their own (as it appeared to be in this child)

June Abstracts

2006-07-10T17:25:00.000-07:00

Here are the June abstracts broken down for you. There's some interesting facts to make note of.
Goldman, R.D., et al, Ped Emerg Care 22(1):18, January 2006: Last time we’ll address this point (and I don’t see it as a problem in our ED or in dealing with our surgeons), pain meds in the ED doesn’t affect the diagnosis of pediatric abdominal pain.
The ASSENT-4 PCI Investigators Lancet 367:569, February 18, 2006: Facilitated PCI (i.e. G2b3a + PCI) in this study TNKase was used- these patients do much worse than patients who solely have PCI. This is a very negative study in terms of adverse outcomes (stroke, etc) with number need to harm 15, number needed to kill 50. The bottom line is if a patient is going for a PCI don’t administer G2b3a prior to it. A very important study to know about. It was done by the drug sponsor though and their thought is they’ll try giving ½ dose and hope that works.
Keeley, E., et al, Lancet 367:579, February 18, 2006: Another meta-analysis that demonstrates no difference in TIMI flow rate, but higher bleeding rates, mortality, deleterious cardiovascular outcomes, (bad stuff) in facilitated PCI. Ergo, I’m not going to be asking cardiologists if they want G2b3a’s to be added if I think they need or are going to the cath lab.
Jimenez, N., et al, Anesth Analg 102:411, 2006 A needless injector system for topical anesthesia (J-Tip) vs EMLA in IV sticks and blood draws showed significantly decreased pain. This is a relatively inexpensive system $2.15 per unit. It makes a loud pop prior to its use (CO2 driven system). It might be something to use as a trial in the ED in our peds population.
Shibata, T., et al, Clin J Pain 22(2):193, February 2006: It’s possible to have a SAH from vertebrobasilar dissection. You need to do an MRI/MRA to diagnosis it and it can happen with seat-belt injuries, chiropractic manipulation, etc. Typically sudden onset headaches with possibly transient neuro deficits. Dissections can have stuttering neuro systems and are unilateral.
Bonsu, B.K., et al, Ped Infect Dis J 25(1):8, January 2006: Traumatic LP’s in determining meningitis- don’t dismiss WBC’s in tube #4 (even if it’s traumatic and has high RBC’s). Treat it as meningitis.
Deng, Y.Z., et al, Neurology 66:306, February 2006: tPA in ischemic CVA had worse outcomes (death and neuro deficits). 9.3 vs 2% mortality. 25% more bad outcomes in survivors. Either way, results that don’t support the use of tPA and show patients do worse with it.
O'Donnell, J.J., et al, Stroke 37:452, February 2006: Nobody should give heparin in ischemic stroke. This is the bottom line and important to know.
Gill, M., et al, Acad Emerg Med 13(2):158, February 2006: The use of Provigil in ED docs after their night shifts to keep them awake during conferences in the morning. This made them a little more alert, but had harder time falling asleep later that day.
Kothari, C.L., et al, Ann Emerg Med 47(2):190, February 2006: Women suffering from domestic violence are often seen in the ED for other CC’s.
Meltzer, E.O., et al, J Allergy Clin Immunol 116:1289, December 2005: Treating rhinosinusitis with Nasonex (inhaled steroids0 may make symptoms a little better. This is a flawed study however and the patients weren’t significantly better.
Foucault, C., et al, J Infect Dis 193:474, February 1, 2006: Using ivermectin in the treatment of body lice with one pill. A nice, easy treatment.
Moser, J.D., et al, Ann Pharmacother 40:45, January 2006: The bioavailability of Phenergan PO is only 25%. Ergo, they recommend using a smaller IV dose that sedates less and may still be effective.
Taylor, M., et al, J Ped Surg 40:1912, December 2005: Most appys do ok if you wait until the morning for surgery if you give them IVF, Abx and pain meds. The perforation rate wasn’t higher and outcomes weren’t worse. This was an underpowered study and not randomized, but supports this option for our surgeons
Barrett, T.W., et al, Ann Emerg Med 47(2):129, February 2006: If someone has a cervical spine injury, they have a higher risk of having significant thoracic vertebral injury. You’ll need to CT the cervical and thoracic spine.
Chana, R., et al, Injury 37(2):185, February 2006: The use of MRI in evaluating occult femoral neck fractures. If you’re concerned about the possibility and they have negative plain films, consider the CT or MRI. These patients can ambulate as well (been documented in the literature) so don’t use that fact as excluding the possibility of that happening.
Spiller, H.A., et al, J Emerg Med 30(1):1, January 2006: In patients with Tylenol OD, they were given NAC and one dose of delayed charcoal (after 4 hours). These patients actually did better. This is a small, non-randomized study however.
Walls, R.M., et al, Ann Emerg Med 46(5):409, November 2005: A review that demonstrated that obtaining blood cultures prior to Abx in pneumonia doesn’t have any benefit or evidence. This is a critique of Joint Commission’s pneumonia’s guidelines. Also of note, Pfizer sponsored the American Thoracic Society’s position on CAP (which became the basis for the Joint Commission’s guidelines).
Zehtabchi, S., et al, Injury 37(1):46, January 2006: The use of serial hematocrits in trauma patients to determine major injuries. The bottom line is a significant drop in the HCT (greater than 5) over 4 hours is important. With regards to IVF’s causing a diluting effect, it only caused the HCT to drop 3 points (vs 1.5).
That's it for this month's abstracts. Be on the look out for LLSA info.

Pharyngitis Phacts

2006-06-22T17:27:00.000-07:00

I'm looking to hit a couple "hot-button" topics coming up. As well I'm trying to set up a LLSA review forum. I'd like to do a little review of pharyngitis. I feel that this is one topic where I see a huge variation in work-ups and evaluation. I think we probably over-test and over-treat this diagnosis. So let's review this, shall we?

Let me start off by saying this is a chief complaint that enables us to perform a lot of patient education. I think you'll find that sitting down with a patient or parent for five minutes will save them time (waiting for lab tests), you time (quicker dispositions) and money (paying for said lab tests and the antibiotics they probably don't need). Also the antibiotic choices I see are varied and too aggressive for a pharyngitis that is a) probably a virus b) self-limiting and likely will get better on its own and c) too broad spectrum when treating one specific, easily treated bacteria. These are important points to consider the next time you're tempted to test and treat.
MOST CASES OF PHARYNGITIS ARE DUE TO VIRUSES. This should probably be the first and last sentence out of your mouth to the patients.
The majority of cases of acute pharyngitis are self-limiting and only need supportive care (again an important discussion point).
Seven million cases of pharyngitis visits annually in the US.
Common viruses behind acute pharyngitis: Coxsackievirus, echovirus, adenovirus, HSV, and EBV (usually associated with LAD, splenomegaly). Consider mono as well (especially in patients with posterior cervical LAD).
Group A Beta-Hemolytic Strep (GABHS) is the bacterial infection that we end up over-treating for.
GABHS is the cause of only 15-30% of acute pharyngitis in pediatrics. It causes only 10% of adult acute pharyngitis cases. These are nice facts to present to patients/parents during your educational talk with them.
Other bacterial causes are Group C, Group G Beta-hemolytic strep, Corynebacterium diphtheriae, Mycoplasma, Chlamydia and Neisseria gonorrhoeae (if you have to ask how it got there, I'm not going to be the one telling you).
Pharyngeal diphtheria typically has the grayish brown pseudomembrane. They can have significant soft tissue edema and cervical LAD resulting in the "bull-neck" appearance.
Most cases of pharyngitis occur in winter and early spring.
Group C hemolytic strep can cause outbreaks (especially in teenagers and adults).
I'm not going to go over the typical clinical features of acute GABHS. I think we're all well versed on this.
Scarlet Fever: A URI due to GABHS with a classic "sandpaper" rash. This occurs because of a pyrogenic exotoxin released by GABHS. The occurence of Scarlet fever has significantly decreased in frequency and virulence over the years.
The rash associated with Scarlet Fever blanches and is typically more pronounced in the flexor surfaces of elbows, axilla and groin.
Scarlet Fever rash typically has its onset 24-48 hours after the first signs of the pharyngitis. It'll typically last 3-4 days and results commonly in desquamation.
The tongue can commonly give a "strawberry" appearance due to desquamation and promient papillae.
So since we know that viruses cause the majority of acute pharyngitis, are there clinical signs that suggest a viral etiology? I'm glad you asked...
The Centor criteria: No longer should these be pimp questions, but educational tools for your patients. The four Centor criteria are a) history of fever b) tonsillar exudates c) no cough, and d) tender anterior cervical lymphadenopathy (lymphadenitis). If the patient meets all four criteria, it's more likely bacterial. Other symptoms consistent with viral pharyngitis are headaches, coryza, cough, rhinorrhea, myalgias, conjunctivitis, exanthem, and odynophagia.
Some have taken the position that you should not test or treat patients with none or only one of these criteria, since these patients are unlikely to have GABHS infection. Again, if they have met ZERO OR ONE criteria, do not bother testing or treating with antibiotics. Supportive care only.
For patients with two or more criteria the following three options are recommended by Internal Medicine docs: OPTION #1) Test patients with two, three, or four criteria by using a rapid antigen test, and limit antibiotic therapy to patients with positive test results. OPTION #2) Test patients with two or three criteria by using a rapid antigen test, and limit antibiotic therapy to patients with positive test results or patients with four criteria (don't test, just treat); or OPTION #3) Do not use any diagnostic tests, and limit antibiotic therapy to patients with three or four criteria.
My personal feeling is that these are a little conservative even for the simple fact that individuals that meet ALL FOUR Centor criteria still only 50% of the time have GABHS. Thus why not simply avoid testing all patients and simply treat the ones who have only met ALL FOUR Centor criteria? Some docs (including myself) take this approach.
Testing: Sensitivity of RSA is 90-95% when done correctly (big caveat). Specificity of most RSA's are 60-95%. Also no test can distinguish those infected with acute GABHS and those that are carriers.
Throat cultures: why bother getting them? They typically need 48 hours to be accurate. Also since RSA's are typically 95% sensitive, what's the benefit. By the time you get the results back, they'll probably confirm what you already know. Also only 50% of positive throat cultures are acutely infected (people can also be carriers).
Treatment: So if symptoms typically resolve in 3-4 days after treatment, why bother? Antibiotics have been shown to shorten the course in 13% by a whopping one day. So again, why bother treating? The one reason to treat is due to the possibility of acute rheumatic fever secondary to GABHS (as a quick aside antibiotics DOES NOT change the incidence of glomerulonephritis secondary to GABHS). With regards to the treatment to prevent rheumatic fever, antibiotics can be delayed up to nine days after the onset of symptoms and still be effective. Other reasons are because GABHS can progress to a PTA, retropharyngeal abscess, sinusitis, OM, or mastoiditis. Again, rare sequelae to GABHS.
Acute rheumatic fever typically doesn't occur for 2-4 weeks after onset of the acute pharyngitis. Post-streptococcal glomerulonephritis doesn't occur for 3 weeks until onset of original symptoms. The incidence of rheumatic fever is typically 0.3% (up to 3% in epidemic outbreaks). Still very small when you consider that only 10-15% of the cases will be due to GABHS AND only 0.3% of those patients could develop rheumatic fever. Your patients probably will have a greater chance of having an anaphylatic reaction to the antibiotics you give them.
IF despite this blog, you're still determined to treat you have only two accetable choices of antibiotics. You should give everyone PCN unless they're allergic. IF they're allergic to PCN then the only reasonable option is Erythromycin. Do not use amoxicillin, cephalosporins, maxipime, etc. GABHS has never become resistant to PCN in cultures. Therefore why use a more broad-spectrum, expensive antibiotic when PCN works perfectly fine?
If you're going to treat you have a choice of either PCN V (oral) or G (IM). I'm a personal fan of IM (I know, I'm sadistic). To me, it's easier to do a one time shot, versus qid oral dosing for ten days. If you ever look at studies that show how compliant patients are when taking 40 doses of a medicine, you'd not even bother writing the Rx. Also if the patient is going to be better in 3-4 days, do you really forsee them continuining a ten day course?
Doses: PCN G 1.2 million units (greater than 27 kg) IM or 0.6 MU if less than 27 kg) one time IM.
PCN V 250 mg PO bid/tid x 10 days in children; In adults 250 mg PO tid/qid x 10 days or 500 mg PO bid x 10 days. (Again is it really worth it?)
Again, if they're PCN allergic, erythromycin is the best alternative.
Thus, if you take away some key points from this, review the Centor criteria with the patient/parents, explain the disease epidemiology, the logic behind not testing and whether antibiotics are warrented. You probably can significantly shorten LOS in the ED, increase patient satisfaction and decrease patient cost.
Hope this was helpful. I'm out.

Bob's Bits

2006-06-07T09:17:00.000-07:00

So I received a request from a partner whose identity will remain anonymous. Let's just call this person "Rob Rarrali"... Well "Rob" requested some info on a couple of topics and since I aim to please, let's try to enlighten the group. In this discussion we'll discuss peritonsillar abscesses (PTA)'s:

To drain or not to drain?
To CT or not to CT?
To Admit or 'vaya con dios'?
What Abx?
When to involve ENT?

To begin with let's review some background information on the subject. Fun useless fact of the day: The other name for PTA is "Quinsy". The diagnosis of PTA is not always easy. Obviously your landmarks can be distorted, trismus may limit visualization and most importantly the hallitosis may prevent close inspection. One case series showed that the clinical diagnosis of PTA is only 78% sensitive (not great). The most common actual diagnosis (if it's not a PTA) is peritonsillar cellulitis. This can as well give you tonsillar erythema and edema.

Why do we care so much about PTA's. Won't they just eventually burst, drain and resolve? Well silly, of course if you want to wait for that to happen, you'll need to hope they avoid airway obstruction. Also, PTA's untreated can resolve in caudad spread with mediastinitis, sepsis and pericardial tamponade. Other than that, they're not such a big deal. All of the literature I reviewed felt that needle aspiration or I&D were required. Not one mentioned observation and IV Abx as being adequate treatment for a true PTA.

Also if you do perform a needle aspiration, the false negative rate for experienced physicians is still 10-12% (likely higher in the inexperienced or those using the patented "Mattison Blind Repeated Stabbing Technique")... Ergo, we want to make sure that there's actually an abscess to drain if we're going to go through this much trouble.

With regards to CT, yes, it's an excellent test in the diagnosis of PTA (nearly 100% sensitive). However, in the acute patient who doesn't want to stay supine or has impending airway issues, I don't feel comfortable waiting for the BMP to be drawn so they can get their CT w/ IV contrast to evaluate and confirm what I already suspect is there (thus delaying definitive treatment by at least 2 hours usually).

So why don't we just stick a needle in suspected PTA's? Well of course, the concern is about tapping into "big red" (aka carotid artery).

An interesting study done by Blaivas et al (Am J Emerg Med 2003;21:155-158) evaluated the ue of bed-side U/S by ED docs to confirm the presence and assist in aspiration of PTA's. Prior studies evaluated intraoral (IO) placement of an U/S probe (which to me is the most difficult part of this study to stomach. I gag brushing my teeth, much less tolerating an U/S probe in my mouth while I already have a PTA - and let's keep the jokes about gagging and probes in mouth to a minimum people)...

Earlier studies showed sensitivities of detecting PTA's with IO probes to be 89-92% while specificity was 80-100%. This particular study evaluated the use of IO probes by ED physicians in 6 probable PTA cases. Three of the cases ended up being confirmed as peritonsillar cellulitis on U/S, while the other three were confirmed PTA and they utilized real-time guidance to perform the aspiration (two of the three originally had multiple blind attempts resulting in failure aspiration was successful w/ an IO probe). Now obviously this is a small N, however it's the only study looking at ED docs using these probes.

Now seeing that we still need a portable U/S probe and the fact that our ENT coverage is improving, I think realistically we won't be doing IO-guided aspirations in the next year. However, if we have the portable SonoSite with an IO probe, it'd be an excellent way to quickly confirm the diagnosis. Plus, if ENT is not readily available, we could perform real-time IO-guided aspiration. Also, the odds of tapping into "big red" are significantly reduced by the IO technique. Finally, there are IO probes that have guide needles already attached so it's point and shoot (no hand-eye coordination required for those video-game challenged).

What about antibiotics? Well obviously in peritonsillar cellulitis IV abx are required (and no I&D). Preferred Abx are PCN + Flagyl. Other choices are cefoxitin, augmentin, and clindamycin. You'll need the same spectrum of Abx for abscesses.

As for ENT consultation, once I have a PTA diagnosed, I try to get a hold of them. It sounds like we'll have some difficulty at MGMC for awhile. The question is whether IV Abx and close observation is adequate. From my experience and point of view, all PTA's need to be seen by ENT that day. If that means having to transfer to another ED and then having them be d/c'd home fine. If that means IV Abx in the ED and the patient being seen in less than six hours, that's acceptable.

Hope this has been helpful. More questions to be answered soon.

Case Report #1

2006-06-04T19:39:00.000-07:00

This will be the first case report. Thanks to Evan for the case. I'll try to provide these in a format that allows you to review the H&P, objective data and then provide some questions with regards to clinical decision making. I'll then provide the diagnosis followed by some learning bullets about the specific case. Ergo, I will withhold some information to allow you to think about the case a bit (ala oral boards). If you have any cases that you think we would be beneficial from a learning standpoint please give me the name and medical record number. These cases can be as simple an interesting x-ray, CT or EKG. The more cases you provide, the more I can put on the site and we all benefit.

I'm still working on some format issues. I don't want the EKG's to be on the top of the blog, but for time being consider the first one to be EKG #1 and the 2nd #2. And now on to case report #1...

CC: "Depressed"

HPI: 76 yo male depressed over a recent diagnosis of dementia. He denies any significant findings on ROS except for depression.

PMHx: Dementia, depression, CAD, HTN, hypercholesterolemia

Meds: Exelon, Triamterene, Digoxin, Lisinopril, Namenda, Pentoxifyline, Zocor

PSHx: CABG x 2

SHx: Denies tobacco or drugs. Rare alcohol use

ROS: Negative for all major systems except depression

V/S: Temp: 98 HR: 78 RR: 18 BP: 167/73 Sats: 98% (RA)

PE: No significant findings except for cardiovascular exam that reveals a bradycardic, irregularly irregular rhythm. Neuro exam non-focal. No other significant findings.

Question #1: Assuming this patient has no history of A-fib, what are some possible etiologies of his new A-fib?

Question #2: If this patient told you he was depressed and took extra medicine, which ones could cause potentially cause the new A-fib?

EKG #1:

An OD panel, cardiac markers and digoxin level were ordered.

Question #3: What are some signs and symptoms of digoxin toxicity?

Question #4: What EKG findings are consistent with digoxin toxicity?

Question #5: What are the criteria for administering Digibind?

The patient was placed on a monitor with a HR of 61. He continued to become more bradycardic. A second EKG was performed.

EKG #2:

Significant lab values included a potassium of 4.8, creatinine of 1.1, ASA, tylenol and EtOH were all negative. The patients digoxin level was 35. The patient admitted to taking #8-10 Exelon 3 mg tablets and #16 Digoxin 0.125 mg tablets two hours PTA. A repeat potassium increased to 5.6. Toxicology was involved early and often. Digibind was appropriately administered and the patient was admitted to the ICU. He later was discharged to a SNF after being cleared by psych.

Learning Points:

Digoxin increases the force of myocardial contraction, thereby increasing cardiac output in patients with heart failure. It affects the Na/K+ pump (remember your biochem).
In toxic doses, the disruption of the pump prevents transport of K+ into the cells, thus you can get toxic hyperkalemia.
Digoxin also increases vagal activity and decreases sympathetic activity. This results in decreased conduction through the AV node.
In digoxin toxicity, you can get both tachy- and bradycardias.
Common digoxin arrhythmias include EVERYTHING, but pathognomonic are A-fib w/ slow ventricular rate, bidirectional V-tach, and atrial tachycardia w/ associated AV block.
Remember as well that digoxin typically gives an ST depression/scooping in the V5-V6 leads "hockey-stick". This is seen even at therapeutic doses. It may help however, in the case of AMS and you don't have a medication list.
As a practice, if any patient is on digoxin and they have any complaint that could possibly be due to digoxin toxicity, ALWAYS CHECK A LEVEL. Rarely does this get done in triage and many times I've had to hold a patient while this gets done. So it'd help if we got the word to the triage nurses to be ordering this (my personal opinion).
The most common constitutional symptoms are nausea, fatigue, anorexia, and visual disturbances (blue-green halo - "Van Gough effect")
The mean peak digoxin level after an oral dose is 2 hours with a range of 0.5-6 hours.
In chronic toxicity, the potassium is actually usually low-normal, but high in acute toxicity.
Digitalis is found in foxglove, oleander and lily of the valley. (Remember these when you get the altered child who may have been eating plants or people who make home-brewed teas).
Patients who are on digoxin are typically also taking diuretics. In these cases they commonly have hypomagnesemia. Try replacing Mg2+ with 1-2 g IV over 2 minutes to help with ventricular dysrhythmias.
Indications for Digibind:
a) ventricular dysrhythmias
b) Progressive and hemodynamically significant bradydysrhythmias unresponsive to atropine
c) Serum potassium greater than 5 mEq/L
d) Rapidly progressive rhythm disturbances or rising serum potassium
e) Coingestion of cardiotoxic drug as β-blockers, calcium channel blockers, or tricyclic antidepressants
f) Ingestion of plant known to contain cardiac glycosides plus severe dysrhythmias (rare)
g)Acute ingestion greater than 10 mg plus any one of factors 1 through 6 above
h) Steady-state serum digoxin greater than 6 ng/ml plus any one of factors 1 through 6 above
There are several formulas for determining how many vials of Digibind you'll administer. My thought is you're not going to remember them (factors include weight, bioavailability -80%, etc). Realistically, you're going to be consulting toxicology anyways AND it's very expensive. Thus, they're going to tell you how much. You also may have to give several doses.

That's it for this first case. Let me know if you thought it was helpful and if you have any cases forward them on.

June Nubbins

2006-06-01T19:34:00.001-07:00

I'm looking to get people together in August some time that we can get together and have a group "review" session for the LLSA test for EMCC. Look for dates and times coming up. Before you take the test this year, you may want to wait for the group.
I'm going to be posting the first patient case blog in the next couple of days (once I get the home office and scanner up and running). Should be an interesting one so keep an eye out for it. Now on to our journal reviews...
Allen, T.L., et al, Am J Emerg Med 23:253, May 2005: PO contrast is not required in CT Abd/pelvis for blunt trauma, especially looking at diaphragmatic injuries. This study is limited by numbers (as you'd expect with a rare injury).
Sokolove, P.E., et al, Acad Emerg Med 12(9):808, September 2005: Big surprise, but a seatblet sign in pediatric patients should clue you into the possibility of abdominal trauma and get a CT.
Topol, E.J., N Engl J Med 353(2):113, July 14, 2005: Editorial from the former cardiology chair at the Cleveland Clinic- bottom line is that nesiritide is NOT a good drug to use in the ED for CHF exacerbation (same results as NTG gtts with a much higher cost and increase in side effects and mortality).
Masip, J., et al, JAMA 294(24):3124, December 28, 2005: Non-invasive ventilation (BiPAP/CPAP) decreases mortality in acute pulmonary edema and should be front-line therapy. These are small, pool studies, but the bottom line is I'm a big proponent of NIV in the treatment of acute CHF exacerbation with respiratory symptoms and pulmonary edema. It has kept me from intubating quite a few patients and given in conjunction with lasix, NTG gtts, and Morphine usually will turn around extremely ill patients within 30-45 minutes. Again, from the "Journal of Mattison Anectdotal Evidence"...
Chen, W.L., et al, Emerg Med J 23:e01, January 2006: A case report (so take it with a grain of salt) of a patient with vertebral artery dissection AFTER chiropractic manipulation. Some info to provide your patients who are interested in this option.
Taddio, A., et al, Can Med Assoc J 172(13):1691, June 2005: Topical liposomal lidocaine provides equal anesthetic relief in 30 minutes when compared to subQ lidocaine. It takes about 30 minutes to be effective (quicker than EMLA) and would be a nice choice in peds.
Kim, T.Y., et al, Ped Emerg Care 22(1):28, January 2006: Lethargy and swelling around the shunt size are the only statistically significant signs of ventricular shunt malfunction (that correlate with CT). Also look for headaches, N/V and seizures. Obviously you'll do a CT (to look for enlarged ventricles). The other films you can order our shunt series (plain film x-rays). I personally have never seen a shunt series that was beneficial. General opinion also agrees with the fact that this does not offer much in the way of work-up (the CT is the key).
Benson, P.C., et al, Ann Emerg Med 47(1):100, January 2006: Emirical IV acyclovir is indicated in suspected cases of viral ENCEPHALITIS. In the cases of viral meningitis, it's not warranted, but if you suspect encephalitis (AMS), go ahead and give it.
Iosif, A., et al, Can Med Assoc J 173(12):1498, December 6, 2005: Not an important study, but it's interesting to note that there appears to be no correlation between lunar cycles and increasing mania or "madness". Thus there is no true "full moon effect".
Lang, E., et al, Can Med Assoc J 174(3):313, January 2006: An interesting study from Montreal where family practice doctors received an emailed transcript of the ED visit, labs, etc. the day AFTER the ED visit. Sounds like a great idea that would improve communication, follow-up, etc. Actually there was an INCREASE in multiple consultations and other factors that you'd assume were improved with this information. It sure sounds like a nice idea though and it'd be interesting if the primary doctors could receive an email of the WEBMEDX typed charts of their patients after the ED visits. Something to consider if feasible.
One CT of the Abd/pelvis is equivalent to 500 CXR's in the pediatric population. A fun fact for parents who are adament about a CT when you don't think it's warranted.
Ozucelik, D.N., et al, Int J Clin Pract 59(12):1422, December 2005: A Turkish study (have to plug that) that utilized Reglan 10 mg IV 15 minutes before NGT placement showed a significant decrease in discomfort and nausea. Consider it the next time you have a patient who's not tolerating or doesn't think they'll tolerate an NGT well.
Jefferson, T., et al, Lancet 367:303, January 28, 2006: Antivirals (neuraminidase inhibitors) for influenza are only efficacious in the acute illness, when treated early and may shorten the course by only 24 hours.
Shafi, S., et al, J Trauma 59:1140, November 2005: An interesting study that supports my experience that intubation with positive pressure ventilation (PPV) in hypotensive trauma patients caused an increase in hypotension and overall lower survival. Obviously there's a selection bias in that the sicker patients needed to be intubated. The take home point is be careful with PPV in hypotensive patients (even if they aren't trauma patients, i.e. COPD).
Christopher Study Investigators JAMA 295(2):172, January 11, 2006: This is a new algorithm looking at PE: a little bit more simple in that you're either a) low-risk or b) non-low risk. You perform a D-dimer in low-risk only and don't treat them if negative. You do a CT angiogram in all the others and treat if positive. There were some technical problems with the study and follow-up stats, but you may be hearing more about this.
Evans, R., Emerg Med J 23:64, January 2006: Very interesting study that examined the use of absorbable sutures in the pediatric population. There was no difference in cosmesis or complications, PLUS there was an actual decrease in dehiscence. The bottom line is that absorbable sutures will do just as well and parents don't have to bring back the child for suture removal. The only question I would have is with regards to facial wounds where you want the sutures out at an exact time frame (5 days) in order to diminish scarring. Other than that any other sutures should be absorbable in pediatrics.
One last reminder for all docs and PA's- when writing for cipro or levaquin (any fluorquinolone) remember that the PO form has 100% bioavailability. Thus if the patient can swallow a pill, give it to them PO. It's much cheaper than IV and works just as well. Also consider how much easier and quicker it is to administer.
That's it for right now. The first case study should be out in a few days.

More Abstracts

2006-05-17T17:21:00.000-07:00

Steg, P.G., et al, Chest 128(1):21, July 2005: Another study sponsored by Biosite (the company that makes BNP) from the BNP (Breathing Not Properly) data base- they state that BNP is better than echo in determing CHF (BNP averaged 683 in CHF vs. 129 in non-CHF). The bottom line is there was a lot of data mining in this study that heavily favored stats towards a pro-BNP stance. I've spoken with a cardiologist from the Cleveland Clinic who feels that BNP is a pretty worthless test in this setting. I really don't bother ordering it anymore as I feel that my clinical judgment (history, physical exam and CXR) provides more information than this one lab test. The only people who I find are still interested in its results are some hospitalists.
Goodacre, S., et al, Ann Intern Med 143(2):129, July 19, 2005: Clinical judgment is as good as the Wells' criteria for diagnosing DVT. The two most important questions are whether they had a prior DVT or current malignancy. Nothing horribly new here.
Oudega, R., et al, Ann Intern Med 143(2):100, July 19, 2005: D-dimer is only beneficial for its negative predictive value in low-risk patients for DVT.
Squire, B.T., et al, Acad Emerg Med 12(7):601, July 2005: Use of bed-side U/S (after a 30 minute training session) to diagnose a superficial abscess is significantly improved. This would be very helpful to determine whether there is some pus there before doing an I&D. This would be a nice adjunctive use of a SonoSite (ahem twice Evan)...
Murray, J.J., et al, Otolaryngol Head Neck Surg 133(2):194, August 2005: Interesting study of confirmed sinusitis (with imaging and bacteriological aspirate) randomized to either Azithromycin 2 g microsphere as a one time dose vs. 10 days of levaquin. Same efficacy between the treatment. A couple of caveats: a) drug-sponsored study and b) they didn't compare to placebo (some patients may have gotten better without treatment). My bottom line is that if I'm going to treat sinusitis (which typically is a 14 day course) it may be beneficial to do the 2 gram Azithromycin dose in the ED and no further antibiotics required. They had a slightly higher adverse effects (23% vs 15%) but not serious (GI issues).
Salerno, S.M., et al, Arch Intern Med 165:1686, August 8/22, 2005: Oral pseudophedrine does NOT cause a clinical increase in SBP or DBP.
Prescott, L., Ann Emerg Med 45(4):409, April 2005: Use of IV N-acetylcysteine is equivocal in efficacy with oral therapy in treatment of acute acetaminophen toxicity. Bottom line is to give oral N-AC if they tolerate PO, but it's ok to use IV in serious overdose or unable to tolerate PO. The maximum effects are found in the first eight hours.
McEvoy, S.P., et al, Br Med J 331:428, August 2005: Not so much that it'll change your practice, but the use of a cell-phone (even hands-free system) is associated with a four-fold increase in MVC's.

Dessert

2006-05-12T13:54:00.000-07:00

here are some more tidbits (this time with citations). I'll be going back and adding citations to the prior studies....

Schwartz, D., Israeli Med Assoc J 7:502, August 2005: routine use of PT/PTT is not required in the general evaluation of ACS. The results don't typically alter the outcome or management. The only time it'd matter is if you're going to start someone on heparin and that still was only seen in one patient affecting management. It'd save $, however I don't realistically see us changing our CP protocol unless there's a good consensus about it
Sabatine, M.S., et al, JAMA 294(10):1224, September 14, 2005 : If somebody is going to get PCI due to STEMI, it's better to load these patients with Plavix 300 mg PO then 75 mg PO q day.
On an aside note while it's in my brain, remember to type q day or q 24 hours vs qd (this is from pharmacy). Also avoid MSO4, MS, etc (use morphine)
Novo-7 will be approved by P&T and will be soon available from the pharmacy. Become familiar with this for treatment in intracerebral bleeds
Fonarow, G.C., et al, Am J Card 96(5):611, September 1, 2005: Some suggestions that there's a benefit to early statins administration in AMI with a decrease in significant bad outcomes. There needs to be a randomized control trial to support these claims. Expect to hear more about this from the cardiologists as it was a focus of their meetings in New Orleans this year.
Morrison, L.J., et al, Resuscitation 66:149, August 2005: Biphasic defibrillation was better than monophasic defibrillation in converting to an organized waveform, but no change in spontaneous circulation, survival, etc. It may help you get a prettier rhythm but no change in survival.
Milling, T.J., et al, Crit Care Med 33(8):1764, August 2005: A significant decrease in cannulating central lines with U/S guidance. This has been seen in several other studies. Bottom line is once we get a portable U/S machine-SonoSite (ahem Evan) we'll be able to significantly improve our TLC placement. I would highly recommend that one of our first inservices with these machines would be on central line placement. Something to keep in mind as well for aggressive early goal-directed therapy for sepsis and perhaps replacing dislodged HD catheters.
Anderson, B.A., et al, Am J Surg 190(3):474, September 2005: PLEASE NOTE AND FORWARD TO RADIOLOGY- to rule out appendicitis, a CT Abd/pelvis does NOT require PO contrast. The only problem is they used rectal contrast (I think I'd take the oral). But still this would significantly decrease our time to CT scan for appy evaluation.
Rady, M.Y., et al, Arch Surg 140:661, July 2005: No difference in ICU patients on vasopressors when treated with corticosteroids, even if they had a high or low cortisol and/or responding to or not to ACTH.
Abraham, E., et al, New Engl J Med 353(13):1332, September 29, 2005: Xigris (very expensive drug) didn't improve outcome/mortality for patients with severe sepsis and caused significant bleeding. May actually do more harm, costs a lot and hasn't proven benefit. Bottom line- I won't be asking the intensivists if we should start Xigris.
Signs/symptoms of botulism are a floppy baby with constipation, ptosis, poor sucking, poor feeding and bulbar weakness. Classically starts with weakness from cephalad to caudad.
Parlak, I., et al, Emerg Med J 22:621, September 2005: IV metoclopramide given as a slow infusion for treatment of cephalgia with or without nausea/vomiting produced the same results with significantly decreased rates of akathisia when given as a bolus (25% vs 5%). Bottom line- consider it in headache patients but give it as a slow infusion to decrease side effects.
Still no studies demonstrating a significant clinical difference between levalbuterol (Xopenex) and albuterol.
DiRusso, S.M., et al, J Trauma 59:84, July 2005: Takes a strong stance that field prehospital pediatric intubation does not show ANY benfit and in fact may produce a negative outcome. It's better to scoop, bag and run.
That's it for this session. Hope these helped...

Late-Night Snack

2006-05-12T00:17:00.000-07:00

The 3rd and latest edition of the PEMS blog. Hope you guys are getting something out of this. I'm going to be culling two more months of abstracts and will then move on to some interesting case presentations. If you have any interesting cases out there, interesting EKG, radiographs or anything else, let me know.

You'll also note the debut of the PEMS logo to the website. I'm still working on getting it to be permanently at the top of the page. Baby steps for the neophyte...

Green, R., et al, Pediatrics 116(4):978, October 2005: Yet another study demonstrating that IV analgesia (morphine) does NOT mask or affect the examination of a pediatric acute abdomen. Not so important at our facilities (always was more of an issue in residency), but still it makes the diagnosis easier because you're able to get a better exam and accurately diagnose a surgical abdomen.
Sanchis, J., et al, J Am Coll Card 36(3):443, August 2, 2005: They looked at patients with CP, a normal EKG and serial negative Troponin's at 6, 8 and 12 hours. Low-risk eh? 5% ended up having a significant bad outcome within 2 weeks (higher risk if older than 67, diabetic, increasing CP, etc). Bottom line is that while we may effectively rule out someone, there's a decent chance that given risk factors they still have an underlying CAD condition.
Shah, M.R., et al, JAMA 294(13):1664, October 5, 2005: This demonstrated no benefit from Swann-Ganz catheters in trauma patients. Doesn't really affect us, but is pertinent from debates during residency with the surgeons.
Tseng, M.Y., et al, Stroke 36:1627, August 2005: Statins used in subarachnoid hemorrhage in order to decrease the incidence of vasospasm (what you want to prevent - why we use Nifedipine); showed some benefit in endpoint outcomes, but some questionable stats. Bottom line is expect to see a greater push of statins used in both SAH's and MI's. Whether that directly affects us in the ED or they just have to be started in 24 hours remains to be seen.
Ghosh, A., Emerg Med J 22:732, October 2005: Steroids in people with idiopathic sensorineural hearing loss. A lack of power doesn't help support the use but there may be a small benefit.
Smith, J.E., Br J Sports Med 39:503, August 2005: Exertional heat stroke (small problem in Phoenix) - evaporative is the best mechanism. I personally have a tech spray them with a water bottle and fans. Ice packs in the axilla, groin, etc take too long and aren't as efficacious. Obviously immersion in ice baths is not appropriate because they either have AMS or are too alert to be comfortable in that position.
Keyzer, C., et al, Radiology 236:527, August 2005: Comparison of U/S vs. CT WITHOUT contrast (novel concept) to determine appendicitis- CT is much better than U/S. The only time I have felt U/S is appropriate is in thin children when you want a quick possible answer, do not want to subject the child to a CT and you don't feel it's a slam-dunk appy (where no imaging studies are required).
Ward, J.I., et al, N Engl J Med 353(15):1555, October 13, 2005: Acellular pertussis vaccine works. There is pertussis seen on the reservation sometimes in Northern Arizona. Also note that pretty soon our Td will also include the pertussis vaccine THAT WE GIVE IN THE ED so become familiar with inclusion/exclusion criteria.
Stein, J., et al, Ann Emerg Med 46(5):412, November 2005: Clinical judgment is as accurate as flu swabs in diagnosing influenza. So of course why order the test if it's not going to change your management?
Knopp, J.A., et al, Osteoporosis Int 16:1281, October 2005: Calcitonin for treating acute pain of osteoporotic vertebral fractures; it doesn't work immediately but within one week patients have dramatic decrease in pain, need for analgesia and ability to perform ADL's. For all the vertebral compression fratures we see in the elderly, this is interesting to note. I'll try to find the exact treatment regimen, but I think this will move to being the standard of care.
Amirfeyz, R., et al, J Hand Surg 30B(4):361, August 2005: The hand elevation test: Elevating the hands for one minute- supposedly a better test in diagnosing Carpal tunnel syndrome. Tinnel's usually is not as valuable and Phalen's a little better. The problem is they used Phalen's as the gold standard. Just more "test name" dropping for the ED
Hauck, F.R., et al, Pediatrics 116(5):e716, November 2005: Pacifiers decrease the incidence of SIDS. Start them after one month and end at one year. Number needed to treat is 1 in 2100. Starting them before one month encourages breat feeding (especially if Barrali's man pecs are nearby). Interesting tidbit though.
Bijur, P.E., et al, Ann Emerg Med 46(4):362, October 2005: Morphine at a dose of 0.1 mg/kg (even in adult) doesn't provide significant pain decrease without requiring opioid antagonists. The bottom line is we're probably undertreating pain at some times, but this needs to be balanced with clinical judgment.
Brown, G., Emerg Med J 22:720, October 2005: there are no sensitive or specific EKG findings in PE. Even sinus tachycardia was found in less than 50% of patients.
Remember you treat accidental epinephrine injection in the fingers with phentolamine.

Tasty May Nuggets #2

2006-05-10T12:11:00.000-07:00

Nagurney, J.T., et al, J Emerg Med 29(4):409, November 2005: CK-Mb more sensitive than Trop I in CP of duration less than 6 hours. If you look at CK-Mb and Trop I at hours 0 and 2, CK-MB has sensitivity of 82% compared to 62% of Trop I. In CP of duration greater than 6 hours, it still is more sensitive. While Trop I is more SPECIFIC, CK-MB is proving to be much more sensitive in determining NSTEMI. Thus you need to check markers at least 6 hours after presentation and realize that IF your Trop's are normal w/ an elevated CK-Mb, you can't blow it off.
van 't Hof, A.W.J., Eur Heart J 7(Suppl K):K36, October 2005: PCI compared to thrombolytics in long-standing CP shows no diffference in outcome. The key bottom line fact is this: IF you can get door to cath time in less than 90 minutes, the pt is marginally better off w/ PCI. IF you can't get them in that time frame OR the duration of symptoms has been greater than a couple of hours, the difference b/w PCI and thrombolytics is pretty negligble. On an aside note, a refresher on revascularization arrhythmias - remember they can happen and you do nothing about them. I'll see if I can dredge more info up on this.
Ray, K.K., et al, J Am Coll Card 46(8):1405, October 18, 2005: High-dose lipitor vs standard dose pravachol in ACS - thus high-dose statins vs. normal dose statins. Not really affecting you in the ED, but you might get it for admit orders or asked by pts. Some data mining from this study and they state that high-dose early statins may be of some benefit. Not a good study and really doesn't bore out anything that should change your practice.
The COMMIT (Clopidogrel and Metoprolol in Myocardial Infarction Trial) Collaborative Group Lancet 366:1607, November 5, 2005: Adding plavix to ASA in STEMI, excluding all w/ PCI and only 1/2 got a thrombolytic. Study treated all w/ ASA +/- Plavix 75mg qd x 4 wks; 10.1% vs 9.2% decrease in significant bad outcomes. Again, nothing that will change your ED care and not a strong study, but something to know about when it comes to talking w/ cardiologists, hospitalists, etc. Done in China and probably not really showing any significant difference in outcome when you extrapolate the data to the U.S.
We break up this cards feast w/ two tasty bite-sized morsels courtesy of P-Mac...
Bakody's sign: Aka "shoulder abduction test"- conducted w/ the pt lying or sitting. The arm is actively or passively elevated through abduction so that the hand or forearm rests on top of the head. A decrease in or relief of symptoms indicates a cervical extradural compression problem (i.e. herniated disc or nerve root compression usually in C5-6 area.
Jolly's sign: If a pt holds their hand on the top of their head to relieve the pain
W/ C5-6 compression watch the pt sit up from a chair, if they have 3/5 triceps weakness they'll deviate to that side to the lack of strength when pushing off the arm rests.
Now back to our regularly scheduled blogging...
The COMMIT (Clopidogrel and Metoprolol in Myocardial Infarction Trial) Collaborative Group Lancet 366:1622, November 5, 2005: IV B-blockers followed by oral B-blockers can cause some hemodynamic instability in STEMI (I know you're shocked), but they do help after two days w/ regards to arrhythmias. Not a lot of strong evidence showing the benefit of B-blockers early on (more benefits later on in course when we're not around). Consider the B-blockers more in a sympathetic overdrive (tachy, HTN w/ CP).
Singer, A.J., et al, Acad Emerg Med 12(10):965, October 2005: Low-risk ACS pts (Negative EKG, negative labs, no clinical findings, no active CP) can be transferred to medical floor OFF MONITORS without a change in outcome. Thus feel free to send the pt OFF monitors with a clean conscience.
Wang, C.S., et al, JAMA 294(15):1944, October 19, 2005: Your clinical judgment and using PE, CXR, etc is a better indicator of CHF vs using BNP. BNP is proving to be a pretty useless test in the ED.
Sen, A., Emerg Med J 22:887, December 2005: Still no evidence demonstrating a positive benefit to pre-hospital ETT and it also results in an increased field time.
Holtkamp, M., et al, Arch Neurol 62:1428, September 2005: In a patient with status epilepticus without a history of sz disorder who's refractory to typical trx (benzos and dilantin) consider encephalitis (i.e. West nile virus, etc)
Yamamoto, L.G., et al, Clin Ped 44 :693, October 2005: Crying doesn't cause pediatric TM's to be red
Leontiadis, G.I., et al, Aliment Pharmacol Ther 22(3):169, August 2005: In bleeding ulcers/UGIB, there's not much benefit from PPI's and really no demonstrative benefit from H2 blockers. This is consistent with other studies.
McGillivray, D., et al, J Ped 147:451, October 2005: Bag U/A vs cath U/A in infants. Bottom line is that bag U/A is about 82% sensitive, but 30% less specific. A reasonable approach is to get a bag U/A in a pt without a history of UTI/pyelo. If the bag U/A is negative, you're done. If it's positive, consider a cath U/A and cx. Never bother getting a culture from a bag U/A.
Badiaga, S., et al, J Emerg Med 29(4):375, November 2005: In a patient who's been travelling to Africa, with fever, jaundice and joint pain- consider malaria.
Thompson, S.K., et al, Arch Otolaryngol Head Neck Surg 131:900, October 2005: Use of steroids in mononucleosis- only indication is in airway compromise or impending airway issues. They don't change admission rate, LOS, or outcome. From the more important "Journal of Anectdotal Mattison Evidence" steroids made me feel so much better when I had mono. And of course anectdotal evidence always trumps hard facts...
Kennedy, M., et al, Ann Emerg Med 46(5):393, November 2005: Blood cx in pneumonia patients who were admitted; 50% of + blood cx were pneumoccocus; 25% staph (who usually didn't do well w/ Abx); 5-7% of admitted patients had positive blood cx. It would take 125 patients with blood cx to have Abx choice changed to make them matter. You'll still probably get the blood cx, but it doesn't usually ever affect management.
Butler, J., Emerg Med J 22:815, November 2005: Crichoid pressure (Sellick's maneuver) has never been confirmed to provide clinical benefit to prevent aspiration. This technique actually was derived from Dr. Sellick who found that three patients had regurgitation of gastric juices after release of crichoid pressure. The BURP technique is probably your best bet.
Anderson, D.R., et al, J Emerg Med 29(4):399, November 2005: If you're going to r/o PE in a pt, you need to do BOTH duplex U/S and CT Chest. One study has shown up to 18% of pt's w/ negative CT chest had a positive duplex LE U/S and later found to have PE.
That's it for now.... Hopefully that will keep you sated for a moment.

"Spoon Feeding" May 2006

2006-05-08T18:40:00.000-07:00

Note: This is the initial "spoon feeding" session. I can provide these on a roughly monthly basis if people think they are of benefit. I'll also be including interesting patient case reports, five-minute lectures and anything else you guys think might be of educational value.

The key to these spoon-feeding sessions is to keep the information simple, concise and bulleted (i.e. bite-sized nuggets of info). If you like this format, have comments or complaints, let me know. Feel free to "blog" your comments, any useful information you have found or other useful tidbits. Consider this a community forum so your input only improves the general knowledge base. Also note that since this is a community forum, pay particular attention to the information you divulge and any patient identifying characteristics. And now on to some tasty appetizers...

Hong, S.N., et al, Circ J 69:1472, December 2005: End-terminal pro-BNP (our new lab test at CRH if I'm not mistaken?) checking correlation between elevated BNP and angiograms in South Korea - relation b/w magnitude of coronary artery occlusion and the magnitude of elevated BNP. There was a relationship between the magnitude of BNP and coronary artery lesions. Nothing in the study will affect your management as the pointy-head statistics didn't show a clinical significance.
Chen, E.H., et al, Ann Emerg Med 46(5):440, November 2005: Telemetry observation admissions (vs. medical) rarely are useful in low-risk ACS pts w/ regards to preventing bad outcomes just because they are on the tele floor. Low-risk patients have a normal EKG, normal markers, and no active CP. Some support for admitting low-risk ACS pts to medical floor. We're already moving towards that path. Free up those tele beds.
Buckmaster, N.D., et al, Intern Med J 36(1):12, January 2006: High-risk ACS pts do better w/ heparin. Low-risk and intermediate risk pts do NOT have additional benefit of receiving heparin. Thus heparin only for the high-risk ACS pts
Remember your high-risk ACS pts are defined by any of the following: a) ST elevation b) > 20 minutes of CP w/ ST depression OR T-wave inversion in 2 or more contiguous leads that changes w/ CP c) baseline elevated trop I d) life-threatening arrythmias e) LV failure f) MI or revascularization w/in 3 months.
Mahaffey, K.W., et al, JAMA 294(20):2594, November 23/30, 2005: Lovenox vs heparin in HIGH-RISK ACS pts - no difference in any major stats b/w the two. These two are equivalent. Heparin is cheaper, lovenox is easier and more convenient. But b/w the two no difference in major outcomes.
Ogata, T., et al, J Vasc Surg 42:891, November 2005: 8-fold higher incidence b/w siblings w/ AAA's - 29% of brothers and 11% of sisters who had a AAA- their sib had one. Consider asking about family hx if you're worried about a new AAA in a pt. This is more of a primary care study, but interesting to note.
Giglio, P., et al, Emerg Radiol 12(1-2):44, December 2005: CT head in routine syncope is not required and doesn't add anything to the work-up. Very interesting if you think how often we order a head CT in syncope. If it's a true transient event with normal mental status, and no focal neuro deficits a head CT is not required or beneficial. This would change my management, how about yours?
Sorimachi, T., et al, Neurosurgery 57(5):837, November 2005: Intracerebral hemorrhages (non-aneurysmal) - anti-fibrinolytics are beneficial with strict BP control with nifedipine (SBP <140).>
Merenstein, D., et al, Pediatrics 116(6):1267, December 2005: If you discuss with parents about the use of antibiotics in peds OM and share the decision-making process with the parents, there's a significant decrease in antibiotic use and increase in parent satisfaction.
Izri, A., et al, Clin Infect Dis 42:e9, January 15, 2006: Washing lice (fomites) with detergent at higher than 50 degrees celsius is required to sufficiently kill them. The key is very high temperatures to kill all the lice.
Pilsczek, F.H., et al, Heart & Lung 34:402, November-December 2005: Consider ordering only PT/INR on coumadin patients, PTT on heparin patients and neither on lovenox patients. Straightforward stuff, but doubt it'll change your ED practice. More of an inpatient consideration.
Remember PTT only evaluates your intrinsic coagulation pathway. This will only be abnormal in hemophilia, vonWillebrand's disease or heparin OD.
Schroeder, A.R., et al, Arch Ped Adol Med 159:915, October 2005: Consider bag urine specimens over cath in infants. If it's negative, you have your answer. If it's positive and you're worried about false positive, then consider a cath U/A. Of course you have to wait for the specimen in the bag and you may still end up cathing them. Of course if it's negative bag U/A you've saved an infant/parents a cath.
Han, Y.Y., et al, Pediatrics 116(6):1506, December 2005: Mortality more than doubled in a peds hospital using computer order-entering system. Demonstrates that current systems are tedious, have inherent errors and sometimes inefficient.
Hippisley-Cox, J., et al, Br Med J 331:1310, December 2005: Increased risk of UGIB w/ COX-2 inhibitors and NSAIDs. No news here.
Babl, F.E., et al, Ped Emerg Care 21(11):736, November 2005: Pediatric pts that are NPO for procedural sedation with nitrous oxide (something we don't have/use) didn't have a change in adverse effects over a non-fasting child. More support for a less strict regimen of PO status in pediatric patients undergoing procedural sedation.
Judge, B.S., et al, Ann Emerg Med 46(5):462, November 2005: There is no conclusive evidence to dive patients with carbon monoxide poisoning. If you have no other option, consider it. There just hasn't been any good studies demonstrating added benefit over high-flow O2. Maybe considerations are a little different because we have it readily available and transportation risks are a minimum. Don't be mad at me Brian.
Kabrhel, C., et al, Acad Emerg Med 12(10):915, October 2005: The Well's criteria in determining the probability of PE hasn't demonstrated significant clinical correlation. Your best pre-test criteria of determining PE is your clinicial judgment and maintaining a high-index of suspicion. Any comments Evan?

That's is for now. Remember, if you find this helpful, let me know.

Erik