Emu Dec 2012

EMERGENCY MEDICINE UPDATE

35 מתוך 1 עמוד

DEC 2012 1) Oh I can feel it all ready- this is going to be a tough month- just way

too many cardiology articles. And I know it is too early for quotes, but what the heck, they are way more fun than the medicine. The way to a man's heart? Right though his chest" Roseanne. Posterior wall MIs account for 7% of all MIs (and probably more, because we miss so many of them) and since you do the EKG on the anterior part of the chest and not the posterior, you can only diagnose these through indirect methods. Obviously if you do leads V7- V9 which are the mirror image of the leads you put on the chest but you just put them on the back- you will pick this up. But there are other clues. A prominent R wave in V1 and V2 can be a good tip off (although you will see this also in RVH). ST depression in the same leads will be a tip off as well although in my experience it is less common. One out of four attendings (or registrars- this was a British paper) missed this diagnosis on a classic EKG. (EMJ 29(1)15) Henoch Hod – a world renowned cardiologist didn’t want to see any MI in the ED until a posterior lead EKG was performed. I just wanted to say hi to Henoch:



TAKE HOME MESSAGE: You can miss posterior wall MIs very easily- look for prominent r waves in V1. Hi five points if you know who this is.

2) Benign dizziness is not a symptom of ICH. (ibid p43). Now this study was retrospective and in those with bleeds, none had a presentation of benign dizziness. That sounds good, but I am wondering- we usually work the other way around- how many cases of dizziness actually have bleeding? Now you may say isn't that the same thing? Could be, but it could be bleeding was smaller and missed, or only noticed days later so it was studied in this paper. In any case I



think the results are true, and there really is no reason to do a CT for dizziness to look for bleeding- an ischemic CVA won't be found on a CT in any case. I am of course not speaking about vertigo of a central cause, or dizziness with other neurological findings. TAKE HOME MESSAGE: Dizziness alone is not a sign of cerebral bleeding

3) So you got this guy who fainted on you and he is only 27. You being the documentation monkey you are cleverly document that there are no signs of Brugada, Long QT, HOCM, and WPW. You may even be real intelligent and say that there is no evidence of an anomalous coronary artery (How would you know?) or catecholinergic polymorphic ventricular tachycardia- but there is one more diagnosis you gotta think about. We discussed this a long time ago- between five and seven years, but remember Short QT syndrome – QTc will be less than 320 (some studies say 360) and to make life even more difficult- one measurement is not enough- they vacillate between normal QT and short QT (Heart Rhythm 9(1)75)



Ok I know what you are wondering- this picture is not funny, why are you putting it in here at all? Well when you google short cutey that is what you get. OK that wasn't very punny so we'll just quote Andy Andrews "whose great idea was it to put a brush next to the toilet? That thing hurts!" If you didn't get it, please write me immediate and let me know in what part of Michigan you live in. TAKE HOME MESSAGE: Short QT is another cause of fainting in young adults and it is serious.

4) Look, I have to be positive despite being a cynic. I am really an awful cynic- I'll give you a quote to show what a cynic I am "Of all the wonders of nature, a tree in summer is perhaps the most remarkable;



with the possible exception of a moose singing Embraceable You in spats.(Woody Allen) . (If the cynicism of this remark is lost on you, its OK, I don't understand what it has to do with cynicism either). So when the chiropractors are producing quality literature I got to give them credit. And in this quality journal they compared manipulations with conventional treatment and found that there is no lasting difference on all parameters, although in week number two- it did show significant improvements in VAS scores and disability improvement. (Arch Phys Med Rehab 132(1)106). Now there are different ways to understand this study. Chiropractic manipulation does seem to make people feel better as a pain relieving treatment (could this be from temporary paresthesia after nerve compression?) but this is temporary and definitely not a cure. Secondly they both were similar after four weeks so this may just indicate that we treat backs poorly and really nothing works that well. TAKE HOME MESSAGE: Chiropractic manipulation shows no long term beneficial effects.

5) Otitis media is one of those things that the treatment has really changed since I started out. In the old days we treated all red eardrums with antibiotics- it was convenient because you covered other bacterial causes for fever in kids who weren't terribly cooperative. Then the articles came out that we don't know how to



even diagnose this entity. Now the Europeans have noted that while giving antibiotics may slightly shorten the disease process, they give a lot more diarrhea. And in addition they all do well in any case. The Americans have their own protocol. What everyone agrees on is that you should treat the under 6 months old patients with 80 mg/kg / day of amoxicillin and treat the bad looking patients as well. (Larynscope 122(1)4) These kids do seem to feel better and get a little better with the antibiotics- the question is if it is worth the price. TAKE HOMEMESSSAGE: Antibiotics may help kids get better a little faster from otitis media but at the cost of a lot of diarrhea.

6) Yea, it will never happen. But look EMTALA is not forever for you Americans, and indeed, at some point, ED overcrowding may make this idea work. Non urgent patients in this Dutch study were evaluated and referred to a near by general practitioner clinic. This is not really a fast track because indeed most patients would continue with the GPs while in a fast track they are still worked up as emergency patients and then returned to the community. (Eur J EM 19(1)14) Would have worked but the nurses were too hesitant on who they could send to this clinic so the savings were minimal. TAKE HOME MESSAGE: There is a good subset of patients that present to the ED who can be returned to the community without any treatment – this may help overcrowding. This month's quotables are from a



contemporary philosophers- Woody Allen- so let's get started- from his film Bananas.

Fielding Mellish: I love you, I love you. Nancy: Oh, say it in French! Oh, please, say it in French! Fielding Mellish: I don't know French. Nancy: Oh, please... please! Fielding Mellish: What about Hebrew? Nancy: [disappointed] Oh 7) LVH is caused by many causes. An EKG can help differentiate

between many of the causes including HOCM, Aortic Stenosis, Fabry disease, amyloidosis, hypertensive heart disease, and cardiomyopathy. The parameters used are the QTC, PQ interval minus the p wave and the Sokolow Lyon index. (AJC 109 (4)587) I will not go through the numbers – cardiology is boring enough and we have already too much cards this month so look up the article if you are that interested. Do not know what Fabry disease is or the Sokolow Lyon index? I hyperlinked you to wikipedia. You'll be a hit at



your next cardiology mixer. TAKE HOME MESSAGE: EKG can help you

identify causes of LVH 8) If you can read this than you are probably not a surgeon, but we do

have some readers who are (yes the upper 10% of the intelligentsia!) and why not use clinical acumen when you are considering acute diverticulitis? If the patient is not ill appearing and can drink- so why do you need a CT scan? Other options for diagnosis are colonoscopy or guided US -the specificity and sensitivity for both these tests are in the nineties. (Dic Colon Rectum 55(2)226) TAKE HOME MESSAGE: Diverticulitis in stable patients can be diagnosed clinically. Nancy: Have you ever been to Denmark? Fielding Mellish: I've been, yes... to the Vatican.



Nancy: The Vatican? The Vatican is in Rome. Fielding Mellish: Well, they were doing so well in Rome that they opened one in Denmark

9) IM midazolam is just as effective and safe as IV lorazepam for termination of seizures and could be given two minutes faster while taking one minute longer to terminate seizures after giving it. (NEJM 366(7)591) I have nothing really profound to say about this relevant research, but the real reason for a rare foray into the NEJM is that it took 168 collaborators to study 448 patients. Wow, is this a government job or what? TAKE HOME MESSAGE: IM Midazolam is fast and effective treatment for seizures- especially when there is no time for IV access. Nancy: I want to go and work with pygmies in Africa... and I want to work with lepers in a leper colony. I don't think that you... Fielding Mellish: I'm willing to... No, that's perfectly OK. I love leprosy! If that's what you're asking me... I'm perfectly willing to... I like leprosy, I like cholera. I like all the major skin diseases.

10) Talking to patients can be tough, and I would not recommend it, but if you do speak to your patients, keep in mind some principles. Use normal language- do not use medical language like “beta blocker” and then explain it- you will probably lose your audience. Speak slowly. Pictures are a great way of conveying information, and encourage questions- ask at the end if there are any and if you can ask them to review what you told them with out getting them angry- this is also good. Do not shame the patients-it isn't their fault they came to your ED and had you as a doctor. (Cleve Clinic J Med



79(2)90) I would add- give patient as much time as they need to ask questions. Try to train patients to write down their questions so they do not have to call over and over again- but rather ask all they want to at the same time. When dealing with people with clear IQ –penia- I am not sure what I would recommend. Any ideas? I am sure Ken has some. Probably published on it at well. Ken? Can you interrupt your caribou hunting and whale blubber smoking to contact us? TAKE HOME MESSAGE: There is an art to speaking with patients- use these tips and never make them feel like they are imposing on you. Esposito: From this day on, the official language of San Marcos will be Swedish. Silence! In addition to that, all citizens will be required to change their underwear every half-hour. Underwear will be worn on the outside so we can check. Furthermore, all children under 16 years old are now... 16 years old! Fielding Mellish: What's the Spanish word for straitjacket? This flash just in- in the latest "where's Waldo" Ken has now been sighted in Uruguay. Or was that Uranus, Ken?

11) Cochrane- impetigo: believe it or not this disease has no established treatment plan. Disinfectants have not been studied enough. Bactroban (careful family docs: Bactroban causes resistance quickly so do not use it for routine cuts) is the most effective but is equal to Fusidic acid. Erythromycin is inferior to them, but better than penicillin. (Cochrane 2012). No one asked the question- what about no treatment?? TAKE HOME MESSAGE: Fusidic acid and Bactroban are probably the best treatments for impetigo Nancy: Can...



can you, like, define the meaning of love? Fielding Mellish: What do you... define... it's love! I love you! I... I want you in a way of cherishing your... your... your totality and your otherness, and... and in the sense of a presence, and a being, and a whole coming and a going in a room with grapefruit, and... and love of a thing of nature in a sense of not wanting or being jealous of the thing that a person possesses. Nancy: Do you have any gum?

12) We're back in the heart- Yoav and Aziz and Shmuel- are you happy? This study out of Haifa. AF is a common complication of acute MI, but it is usually transient. Do these people go on to stroke? According to this study they do have a higher risk, especially if they are taking anti platelet agents alone without anticoagulants. (Thrombo Haem 106(1)6) Yes maybe, but this is a hard one to call. After all, they checked this one year later, and many patients who have MI are vasculopaths anyhow so the stroke could have come from carotid stenosis and not AF. Nevertheless, a secondary endpoint documented a lot of A fib recurrence so perhaps oral anticoagulation is a good idea. But even that is not so clear from this study- maybe the recurrences were all early on and indeed, later they didn't have them. Or perhaps they were transitory. While we are on the interesting subject of a fib (really, is there any geek around who finds atrial fibrillation interesting?) another point well taken is that atrial fibrillation can be caused by eating or sleeping- basically anything causing vagal stimulation. (Pace 35(1)104) TAKE HOME MESSAGE: Afib can be caused by anything that causes vagal stimulation



Recurrences are common after MI- question is – do they go on to stroke and do you need to treat them?

13) If the last paragraph left you in a fog, this one will too. Pediatricians love to work up the urinary tract if there is an UTI, because there could be vesicoureteral reflux that could lead to renal scarring and subsequent renal failure. The incidence in the studies is between 1 in 154 (which may be concerning) to 1 in 199900 which is not only not concerning, it isn't interesting at all. These vastly diverse numbers (if you are an orthopedist there is a big difference between these numbers) is because of different assumptions and varying data sources. (ACTA Paed 101(3)278) TAKE HOME MESSAGE: I am not sure these big workups for renal scarring and reflux are worth it. This is from Annie Hall: Doctor in Brooklyn: Why are you depressed, Alvy? Alvy's Mom: Tell Dr. Flicker. [Young Alvy sits, his head down - his mother answers for him] Alvy's Mom: It's something he read. Doctor in Brooklyn: Something he read, huh? Alvy at 9: [his head still down] The universe is expanding. Doctor in Brooklyn: The universe is expanding? Alvy at 9: Well, the universe is everything, and if it's expanding, someday it will break apart and that would be the end of everything! Alvy's Mom: What is that your business? [she turns back to the doctor] Alvy's Mom: He stopped doing his homework! Alvy at 9: What's the point?



Alvy's Mom: What has the universe got to do with it? You're here in Brooklyn! Brooklyn is not expanding

14) Steve Selbst's legal briefs. I did pretty well this month, but a few pointers. You got be careful with those CVPs. He presents two cases of fluid bounding into the thorax from misplaced lines- if you not sure where the line is then don't open up the fluids. He also brought a case of a patient that was drunk and discharged- while waiting for his wife to pick him up- he went out into the street to get into her car- but it wasn't her, and he got hit by a car. (PEC 28(2)208) While we are at it, if you put in your CVP in a sterile fashion and take it out by day 9, you can have zero infections. Considering most ICU patients have their CVP removed by day 7, this could be attainable. (CCM 40(2)388) TAKE HOME MESSAGE: Carful with CVPs insertion, and if you do it right, your patient can enjoy his CVP worry free for a week.

15) I don't know what you have against lice- they are cuter than roaches, brown recluse spiders, Lady Gaga etc. Ivermectin does work, but there is a new boy on the block – Spinosad which seems to do the job as well. Spinosad is safe and works well, but still misses 15%. (Clin Ther 34(1)14). By the way, hospital food was also effective in killing lice. And in order to be more interactive (whatever that means)- let us present one of the most famous cafeteria scenes: http://www.youtube.com/watch?v=DZN4r8p6KbU TAKE HOME MESSAGE: Spinosad seems to help in the war against lice. If you do



not have youtube- here is something to get you into the mood for

lice. 16) Acetaminophen (paracetomol)poisoning remains a significant

cause of mortality, and the author of this paper wants you to know that the antidote –NAC – has never been studied in a systematic matter to show it works, and also, the nomogram was determined rather arbitrarily based on SGOT and SGPT levels. We also do not know when more or less NAC is needed under certain conditions. (Clin Tox 50(2)91). So you are saying- if nothing is certain, why do you need to tell me this? A little respect, will ya? The author of this pare was Rumack himself- the inventor of the nomogram .TAKE



HOME MESSAGE: Be aware that the nomogram is not 100% and has never been proven

17) The kid hit his head. Then he vomited. No neuro signs, no other complaints- just vomiting. So you did a CT scan- did you have to? This study says that there are very few that came out positive for kids or adults and indeed, none needed neurosurgical internvention. so maybe it isn't a rush to do these on vomiting alone (BJR 85(1010)183) This study was small, and retrospective and that is a real problem. I would not do a CT on one episode of immediate vomiting; I would do a CT on later recurrent vomiting- 3- or four times. How bad did these folks look? Can't know. TAKE HOME MESSAGE: Vomiting alone is not a reason to do a CT in head injury- perhaps. Some guy hit my fender and I said "be fruitful and multiply" but not in those words”

18) Gosh, I feel bad for the Americans- they got to work nights. And this study made it clear that after working nights they have worse sleep quality and when tested for short term memory, they did poorly. (AEM 19(1)85) The sleep quality is true from other studies, but doing word memory testing is the wrong test. I want to know about long term memory and decision making ability. Interestingly enough, day shift workers did worse with word memory after completing a day shift when compared to before starting to work-



could it be we work awfully hard? Nah! TAKE HOME MESSAGE: Being tired does affect us- not sure how though.

19) Here is another bone for Ken who actively reading his EMU by fluorescent light in his igloo on Devon island (Resolute) (no I did not look any of this up- nor did I look up the capital of Uruguay which is Montevideo. I am not sure what the capital of Uranus is- Fissure? ) and this reminds me we haven't gotten on Father Greg's case this month- I think we will give him the month off. Being a mentor is actually great for personal satisfaction, longevity at work, builds networks, and self motivation The problem is these conclusions were made from the business and psychology literature, there are very few studies in the EM lit(AEM 19(1)92). I am doing it now and enjoying it. TAKE HOME MESSAGE: Mentoring is probably good for you and your protégé, but let's get a good EM study." I took a speed-reading course and read War and Peace in twenty minutes. It involves Russia"

20) OK, smarty pants, try to figure the diagnosis here. Gingival hyperplasia, bleeding under the skin, red papules, and no fever. The case is a 10 year old autistic boy (Ped Derm 28(4)444). If you get the answer then you are premier internists. But I believe all internists without exception should be drawn and quartered, tarred and feathered, and proctored and gambled. So do you feel lucky? And



let's get interactive again- the best do you feel lucky scene in history: http://www.youtube.com/watch?v=8Xjr2hnOHiM http://www.youtube.com/watch?v=8Xjr2hnOHiM

21) If you take statins(gosh, are we back to the heart again?) then you will have a higher CPK after physical activity- and it doesn't matter which statin you take. (Lipitor stock just dropped to 1800000 1/3 (AJC 109(2)282) Could be, but this study was a little exaggerated. It was done on marathoners from the Boston Marathon and the average difference was only 300-1100 in those who didn't take statins versus 813. Does this make a difference? How about for milder exercise? I wouldn't prevent my statin user from exercising TAKE HOME MESSAGE: Statins use in sporting events may cause a slightly higher CPK. This one is from Sleeper: Miles Monroe: I'm what you would call a teleological, existential atheist. I believe that there's an intelligence to the universe, with the exception of certain parts of New Jersey. And here is one from What's Up Pussycat: Dr. Fritz Fassbender: My wife, the creature that ate Europe, is here.

22) Calf DVT- 8% will propagate. This is a lot less than I thought. Should you use Coumadin or just watch and wait? Do not forget that the bleeding rate from Coumadin can reach 6%. As usual no clear answer, but this much this study gave me- post thrombotic syndrome and recurrence of DVT is much less in the calf (J Vasc Surg 55(2)550). TAKE HOME MESSAGE: No real good advice on how to



treat calf DVT, but it is probably better to have a calf DVT than a thigh one. This one comes from Play it Again Sam:

Allen: That's quite a lovely Jackson Pollock, isn't it? Woman: Yes, it is. Allen: What does it say to you? Woman: It restates the negativeness of the universe. The hideous lonely emptiness of existence. Nothingness. The predicament of man forced to live in a barren, godless eternity like a tiny flame flickering in an immense void with nothing but waste, horror, and degradation, forming a useless, bleak straitjacket in a black, absurd cosmos. Allen: What are you doing Saturday night? Woman: Committing suicide. Allen: What about Friday night? 23) There is a subset of COPD that does worse- those with high

troponins. This elevation could be due to cor pulmonale but it could also be related to PE- COPDers have a 15-25% higher incidence. (Thorax 67(2)177). Now I do not know how they know this because we probably miss a whole lot of PEs in COPD, but after reading this, you won't- right? TAKE HOME MESSAGE: PE occurs more frequently in COPD- there may be a case to take troponin.

24) This is, Ladies and Gentlemen- the paper of the month. It gives the whole answer in the title which will make Rick Bukata happy, and it goes against the dogma which makes me happy. Those smelly ethanol waterless rubs you wash your hands with after seeing patients (well maybe not you- but most of us do) are ineffective



against rhinovirus. Soap and water did better although not great either. (J Med Vir 84(3)543). Now if both poorly kill the rhinovirus- so why is soap and water better? I surmise because we tend to clean our hands longer with it and wipe off more virus. TAKE HOME MEGSSAGE: Wash your hands with water and soap- the alcohol stuff is icky, smelly, gets a bad taste in your mouth, clears out the cafeteria and is worse than soap and water. Of all the famous men who ever lived, the one I would most like to have been was Socrates. Not just because he was a great thinker, because I have been known to have some reasonably profound insights myself, although mine invariably revolve around a Swedish airline stewardess and some handcuffs.

25) Tongue piercing- where else are you going to see an article about this? While are you wasting your money on EM Reports-EMU is the way to go, baby! This practice will cause more enamel cracks and lingual recession of teeth. (Clin Oral Inve 16(1)231) it also may get y our tongue stuck in the beer bottle, right Chris? While I presented this as a tongue in cheek article (oh, that was terrible) it was a serious study. TAKE HOME MESSAGE: Tongue jewelry can cause damage to teeth. What has gotten into you lately? Save a little craziness for menopause! (Manhattan Murder Mystery- also Woody Allen) Taste my tuna casserole — tell me if I put in too much hot fudge (same movie)

26) This is it guys- no more cardiology for this month. One more cardiology article and I will go out and get my tongue pierced.



Clinical Caridolgy 35(1)3 looked at the new ACCF AHA guidelines for patients with NSTEMI and unstable angina and found that in lower risk patients, there really is no advantage to going to PTCA immediately and even a delay of 50 hours did not show improvement over maximal medical therapy. The question is –what about more than 50 hours? Maybe PTCA isn't necessary there either. TAKE HOME MESSAGE: You can wait to do PTCA in low risk NSTEMI patients – maybe even indefinitely.

27) It is time to stop playing around. While testicular torsion in adolescent men is the third most common cause of malpractice in that age group; 31% of these cases are atypical. Lets' deal with some of the myths so you won't fall into the same ditch. Physical exam is not good enough to rule in or out torsion. Even if you can feel that inflamed epididymis, not good enough. Even if there is no cremasteric reflex- well that is absent in 30% of males anyhow (and more in women) so you could still miss torsion if you depend on that. Erythema of the scrotum, edema and testicular swelling can be seen in epididymitis as well as orchitis and torsion of the appendage. A vertical lie can still be torsion- it doesn't rule it out at all. (Although a horizontal lie should set off the lights and sirens). Epididymitis can have a rapid onset, so suddenness doesn't help you. Urinary symptoms can be present with torsion too. Nausea and vomiting can



occur with epididymitis. Did they tell you only have six hours? Well that is if you have dog testicles (do you? You can tell me, I won't tell anyone -woof woof). You may have considerably less time. But then again, there is a 50% salvage rate at 12- 24 hours so don't throw in the towel if they come late. 48 hours is probably the limit. Testicular blood flow says nothing, so ultrasound can miss a lot. A torsion knot will help, but is rarely seen. Torsion can occur in older men. In a study of closed malpractice cases- the mean age was 24.3 years – no longer adolescents (but still acting like one) with four patients that were older than forty (PEC 28(1)80). I have heard that local anesthesia and exploration may be the best way to diagnose this, but for the ED doc- just get the urologist there early, do not waste time on tests, and do a detorsion if you have no backup. TAKE HOME MESSAGE: Physical exam can not rule our torsion and neither can ultrasound.

Allan: You want a Fresca with a Risperdal? Linda: Unless you have apple juice. Allan: Apple juice and Risperdal is fantastic together! Linda: Have you ever had Valium and tomato juice? Allan: No, I haven't personally, but another neurotic tells me they're unbelievable. Dick: Could I get a coke with nothing in it? 28) Blood pressure monitoring is not cardiology per se, so I do not

have to pierce my tongue. BP used to be measured by a column of



mercury. But mercury is has environmental concerns, and so, these sphygomano-oh forget it- blood pressure monitors are on the way out. The ones that replaced these- the aneroids (not hemorrhoids- gosh, you have a one track mind) worked with the dial and no mercury. They have varying specs, and need calibration fairly frequently. Hybrids are like mercury ones, but has an LCD column instead mercury but these need clinical validation against- you guessed it- a mercury sphygmoman-gizmo thing. Oscillometric devices are in wide use and are a little more expensive. They work on a different principle but still need initial calibration against mercury devices. After that they are fairly maintenance free and accurate but arrhythmias can mix them up. (J HTN 30:537) TAKE HOME MESSAGE: Mercury devices for blood pressure measurement are on their way out- the automatic ones are the best way although arrhythmias can mix them up. I was nauseous and tingly all

over. I was either in love or I had smallpox. 29) Red bull time. I dare you to stay awake after this paragraph- . If

you are reading this in the bathroom- and you should be- please do not strike your head on the stall door when you nod off. We are speaking now on two of your favorite subjects- Vertigo is first. The writers of this paper think you overcall Meniere's disease. This can



be due to auto immune vasculitis, syphilis, mumps, trauma - but most cases are idiopathic. It starts in middle age with relapses and that finally cease after many years. It is severe rotational vertigo with tinnitus and hearing loss. Now there are guidelines for diagnosis, and you can do audiograms, and electrocochloegraphy but the question would be – for what end? The treatment in the ED will be the same as for garden variety vertigo. The real difference is surgical with various nerve ablations but this is not something you will do in the ED or in the office. (Int J Clin Pract 66(2)166). Still awake? Well let's then talk about syncope. Yea, you know- that 10-47 % never reveal a cause despite all our investigations. What we do know- TIA and stroke are not a cause of syncope. Vasovagal syncope remains the most common cause even in the elderly. Tilt testing which I thought wasn't great seems to be the best in diagnosing this. Just do not forget medications as a cause for vasovagal syncope. Myoclonic jerks occur so do not assume a seizure- there will be no post ictal state, tongue biting or incontinence. Serious injuries can occur even with this benign diagnosis. Carotid sinus hypersensitivity occurs- carotid massage (no, not Swedish massage) will help diagnose this, but please do this with care- Any stroke history or TIA history is a contraindication. It occurs more commonly in people with cognitive decline. Orthostatic hypotension is an easy one- it is positional.



Remember medications, Parkinson's, diabetic and alcoholic neuropathy, Addison’s, malignancy and anemia. Syncope with heart disease, during exercise or with chest pain- better consider cardiac causes. An external loop recording may be necessary to catch the cause. Treatment: Vasovagal- anticipate and sit down quickly. Carotid sinus- same, more complicated may need a pacemaker Orthostatic-same, perhaps steroids if tolerated. (Int J of cardiology 155:9) TAKE HOME MESSAGE: Syncope can often have an identifiable cause nowadays and treatments do exist. Meniere's disease can be helped surgically if our regular forms of treatment for vertigo do not work. "You don’t have to see a shrink. There’s nothing wrong with you that can’t be cured with a little Prozac and a polo mallet. " "The key here, I think, is to not think of death as an end. But, but, think of it more as a very effective way of cutting down on your expenses."

30) Answer to quizzes- that guy in 1) is Alice Cooper who was a very sick musician during the heavy metal days- which was before the Macarena days. Anyone remember him? Number 20 was scurvy. That is vitamin C deficiency which should be differentiated from acute valium deficiency which is much more serious.

31) Time for letters (Zehirut- the link is Kol Isha) First we hear from Marvin Wayne discussing his experiences with intranasal Narcan:



Nice job. We have been using intranasal narc an for many years with great success. We try to give the minimal amount atomized to get pt breathing. Waking up is optional: Marvin

Rafi Kayam took issue that I said he was handsome. He claimed there is no evidence and being that I am all EBM, this cheapens EMU (honestly Rafi, can EMU get any cheaper??) But Rafi, you are a great boss, but you missed an important study, from the journal called The New England Journal of Great Looking Guys. Evaluating the looks of Medical Directors

Leibman YB

Handsome Research Group, Israel

Abstract

BACKGROUND:

Medical directors are universally thought of as being unattractive. There is some evidence of this being true.

METHODS:

We performed a questionnaire based study of the Medical director of Leumit HMO services in the Jerusalem Area. There was 100% response rate (N of one- the author of the paper). Results were analyzed through normal regression analysis



RESULTS:

One questionnaire was returned but only one was distributed. The results revealed a perfect correlation (100% , standard deviation of +/- 0) There was universal agreement by all that filled out the questionnaire that this medical director is handsome

CONCLUSIONS:

In this trial, it was found that this medical director is handsome and should not be seen in public unescorted.. Now can we speak again about that raise?. (Declared conflict of interest – the subject is the author’s boss .ClinicalTrials.gov number, NCT0123456.).

Next, I was taking to task by a senior member of the League Against Criticism To Acute care Teaching Experts (L.A.C.T.A.T.E) Scott Weingart who says you could easily miss a very sick patient who looks great but will be soon going down hill, so he recommends lactate measurements for all patients with SIRS and if it is greater than 4- get moving on seriously treating them with fluids and antibiotics. H e was kind enough to give us the link to hear more about it. all is here my friend http://emcrit.org/podcasts/lactate/ let me know anything else you need Scott.

Next Scott Shapiro MD gives us some more on probiotics from Medscape- here is the link: Probiotics

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Dr. Simcha Shapiro

Thank you Scott Nurse Sherri, sent me some material about Flaming Hot Cheetos which are causing an increase in ED visits in the USA. In truth, like beets – this can cause red stool but otherwise is harmless. However many school districts are banning it because it lacks any nutritional value. I could say they same about EMU. Thanks Sherri. Sherri does hate Woody Allen (so do I but he is funny) so we'll leave off with one last quote of his from Sleeper. Miles Monroe: You remind me of Lisa Sorenson Luna Schlosser: Who? Miles Monroe: An old girlfriend from the village. A Trotskyite, who became a Jesus freak, and was arrested for selling pornographic connect-the-dot books. EMU LOOKS AT: Coughs and Colds and Flint Michigan Without out further ado, let's look at our three essays today: Coughs: Pertusis is back, and it is angry. Let's give you a quick rundown. The source for this essay is PIDJ 31(1)78

1) This bug gets around more than a handsome man (see above). It is spread by droplets and an index case can cause more than 17 new secondary cases. It is more severe in babies where it can cause respiratory arrest, and since immunity wanes over the years,



immunized grandparents and siblings can easily spread this disease to infants.

2) Looking for that whooping cough, vomiting after cough, fever? Most of the time you won't see it rather you will see just a URI. A tip off might be a chronic cough which just doesn't improve (URI coughs can take three weeks to get better ,but they improve)

3) Serologic tests can be poor at diagnosing this as they aren't standardized. PCR looks promising.

4) Once in the paroxysmal coughing stage, antibiotics won't help shorten the course of the disease, but will help reduce the contagiousness of the index case.

5) Prevention- Maybe- I don't like this idea- you can give antibiotics to high risk kids but getting a booster is the best way. I am a new grandfather. Guess what- just got my booster!

We aren't really going to speak about Flint Michigan again – also we promised to leave Father Greg alone this month and while my invitation to Australia to lecture never came through, I am at least waiting for a speaking engagement in Flint. After this paragraph that will probably not be in the near future; but you never know. In any case, we are speaking now about eyesores. That is periorbital cellulitis and orbital cellulitis. The source for this article is Pediatrics in Review 31:242



1) They taught me that the orbital septum that sprats the superficial structures of the eye from the deeper ones is very thin in kids so these folks need a CT to rule out spread of periorbital cellulitis to deeper structures. Truth be told, periorbital celllulitis is a pediatric disease- I haven't seen too many cases in the adult population. We all know that sinusitis can cause this, but so can a hordeolum, dacryocystitis and dental abscesses as well. Your bugs of choice are Staph, Strep and MRSA.

2) Orbital cellulitis is the easier one to diagnose- there will be ophthalmoplegia, proptosis, chemosis and blurred vision. This will not be present in periorbital cellulitis. The biggest problem with periorbital cellulitis is differentiating it from other causes of eyelid swelling including allergic reactions, and insect bites. Use your clinical judgment- no room here for labs or rays.

3) There is an entity called orbital pseudotumor. This is an additional cause of proptosis as are cancers and Wegner's and Sarcoid- you'll need a CT to know exactly here.

4) Perioribital cellulitis does fine with oral antibiotics. It takes about 24- 48 hours to improve. If you think the periorbital cellulitis came from hematologic seeding then you need also gram negative coverage and admission This will be in those kids under the age of three who look



sick, have rapidly progressing swelling and usually have antecedent URI

5) Blood cultures do not help much. Culturing eye discharge may help 6) Recurrent periorbital cellulitis is a real entity and is not necessarily due

to treatment failure. Atopy, herpes, CVD and neoplasms must be considered.

7) Orbitral cellulitis can be cause cavernous sinus thrombosis- but the signs are similar to orbital cellulitis. Ophthalmoplegia, proptosis and periorbital edema are present, loss of vision and meningismus are late findings.

Colds- hypothermia is a subject most of us are weak on so, I thought I would present the article from the recent NEJM on this (367(20)1930) 1) Definition – temperature less than 35 C (that 95 F for you stuck in the

past guys) 2) These people get confused- they can even undress when their core

temp gets to 28 C. A fib shouldn’t bother you- it happens very frequently under 32. V fib should bother you – that is very common under 28 C



3) There really aren't any very accurate ways of measuring temperature in such people- what is most accepted is a thermistor probe in the esophagus in an intubated patient.

4) Don’t forget other causes of hypothermia including CVA, DKA, AKA, hypoadrenalism, burns, hypothyroidism, sepsis

5) There are a lot of fluid losses so you will need a lot of warmed (38-42 C) fluids. This fluid loss is called cold diuresis and is due to less ADH and vasoconstriction. ECMO or bypass should be used for patients who are unstable. CPR should be continued until the patient is "warm and dead" Thoracic lavage should be considered if you have no ECMO

6) This article really doesn't deal with the lab abnormalities of hypothermia and more practical aspects- I found Danzl's work much more comprehensive – he wrote on the subject in the NEJM in 1994 and in Sem CCM in 2002. Not clear why we haven't heard from him in a while.

Hey that is all for this month- 2012 was a great year and we hope you enjoyed EMU. Actually we hope that you even read EMU. Or that your canary did. As is our custom – we use this issue to thank our dedicated peer reviewers – I thought about it- with the exception of long time friend Mike and Yechiel, I have met the others only once and Chris never. This isn't dedication to me- it is dedication to you the readers- Think about that. Thanks guys- I appreciate it more than you will ever know



Mike Drescher Associate Professor Division of Emergency Medicine Hartford Hospital/University of Connecticut

Tom Ashar MD FACEP ED Director Community ED Group in Alabama

Pegasus Emergency Group



Moshe Weizberg MD FACEP Residency Director Staten Island University Hospital

Chris Nickson

Emegency Phsycians and CCU specialist

Alice Springs Australia

Gil Shlamovitz, MD, FACEP Assistant Medical Director of Clinical Information Systems Harris Health System Director of Medical Informatics, Section of Emergency Medicine Assistant Professor, Department of Medicine Baylor College of Medicine, Houston, TX

And to our reviewer in a pinch

Yechiel Reit MD FACEP



And new volunteers are always welcome! (Like the above,

they must have been featured in the New England Journal

of Great Looking Guys And our yearly review of policies:

EMU Policies: 1) EMU is distributed free of charge 2) All parties with the exception of for profit organizations can reproduce it. It can not

be reprinted for profitable purposes 3) EMU is peer reviewed 4) EMU does not accept advertising 5) EMU does not usually quote articles from Annals of Emergency Medicine and the

New England journal because most of EMU’s readership already receives these journals. EMU also does not generally use articles reviewed in Emergency Medicine Abstracts as many EMU readers are subscribers as well, and I do not wish to take away from that excellent publication.

6) I have no connections to any drug or medical appliance company, and thus the information in EMU is objective.

7) EMU is dedicated to the development of Israeli and International emergency medicine. Therefore, new subscribers worldwide are welcomed, and we appreciate your referrals.

8) That is it, friends- 14 years publishing monthly. I hope you have enjoyed it as much as I have.

Emu Dec 2012

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