September EMA Abstract Review

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

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.

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

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

• 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

• 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

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

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

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

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.