Emu Sept 2013 Part 1

7/27/2019 Emu Sept 2013 Part 1

1/23

EMERGENCYMEDICINE UPDATE

SEPT 20131)Adenxal torsion- well, here is a score to help you- abdominal pain,

ovarian pain, "unbearable" pain", vomiting and absence of

menorraghia were all assigned points and these help make adiagnosis.(Hum Reprod 27(8)2359). I think this is silly. They only saw

31 patients with this out of 431 patients with pelvic pain and to tellyou the truth- like testicular torsion- there does not seem to be subtle

cases- if they have they will look sick. I mean like-

D'oh TAKE HOMEMESSAGE: Adnexal torsion patients look sick. This is not a diagnosis

you should miss.2)Rare that I bring a NEJM article but this one is so EM (and written by

an EP) and yet had important points. Yeh, you know the opiodsyndrome- respiratory depression, miosis (absent in cocaine, and

pethadine (which in the states is meperidine) and in poly ingestion,stupor, hepatic injury, myoglobinuria, rhabdo ,and hypothermia. Butthere were some points that would be a shame to forget. Do not

7/27/2019 Emu Sept 2013 Part 1

2/23


forget Fentanyl patches that can be on the body that can be in placesthat you may miss, and also kids can chew on these and get the opiodtoxidrome. Remember paracetomol (acetaminophen) levels as

Perccoet and the like have this ingredient. Studies show that urine toxscreens rarely help. Narcan (nalaxone) can help but the half life is too

short for most ingestions. No IV? You can give this by intranasal orinhalation routes, but not orally (although there have been studies in

the past that trans buccal works). (NEJM 367(2)146) I would exerciseextra caution with methadone as the bio absorption is erratic andthese patients can crash and burn many hours later. TAKE HOME

MESSAGE: No tox screens. Narcan may have to been given bycontinuous effusions. Do not forget fentanyl patches as a source ofopioid OD. We look into the media this month- Tabloid headlines-

7/27/2019 Emu Sept 2013 Part 1

3/23


Let's get started

3)If you are a long time reader of EMU, you know I love the work of Paul

Marik, and ICU guy that was at Allegheny General and now is at EastVirginia. He did a metaanalysis and found that new evidence seems to

confirm that if your patient is not obese the infection rates offemoral versus IJ versus SC CVPs are about the same. (CCM

40(8)2528) This is contrary to guidleines, and it is a meta analysis-which may not be worth much, but I think it a least opens the door.TAKE HOME MESSAGE Femoral CVPS may not be more infection

7/27/2019 Emu Sept 2013 Part 1

4/23


causing.

4)EMU goes to 27 countries and it is possible that you have camelsroaming around your country or something similar that drinks a lotbefore going to work. Yes, you USA guys- there are camels in Arizona

from a failed military experiment form long ago. Camels are notpleasant animals. They bite, they spit and they can pick you up and

throw you. Injuries are usually severe, and these animals areparticularly disagreeable (and dangerous) during mating season.(Injury 43(9)1617). Worth noting that all injured patients were males

7/27/2019 Emu Sept 2013 Part 1

5/23


and that they only saw 33 patients in six years, but that could bereferral bias. Another interesting point and this isn't meant as aninsult- (camel jockey is consider derogatory) but 12 percent were

actually camel jockeys and all of these children and this may explainthe severity of injuries TAKE HOME MESAGE: Don't marry a camel- you

are asking for trouble

7/27/2019 Emu Sept 2013 Part 1

6/23


5)TRALI- some review and new things. What is TRALI you ask?

It is transfusion related acute lunginjury. There are risk factors for this- liver transplant patients, alcohol

abuse, shock, hyperkalemia, patients getting whole blood and multipletransfusions, and those with anti HLA and anti HNA type blood( notsure if your patient has this? Ask your resident vampire he is sure to

know) Speaking of vampires- here is a picture of Grand pa- who

7/27/2019 Emu Sept 2013 Part 1

7/23


played him and on what series?Interestingly enough female blood also seems to cause more TRALI

so be careful about giving girl blood to these other patients with risks(why is this? Previous auotantibodies?) What are the sympthoms?

dyspnea, tachycardia hypoxemia, fever-+/- and most importantly pulmonary infiltrates that are not CHF. Treatment is supportive andECMO. (Crit Care Clinics 28(3)363). TAKE HOME MESSAGE: TRALI has

7/27/2019 Emu Sept 2013 Part 1

8/23


risk factors so please be careful when you give blood and look for

shortness of breath

6)Important point here. I worked in a place where you could not takeblood cultures if the patient was being discharged. I worked in places

where you took blood cultures on all patients- -however I neverworked at a place where you took them on selected patients even if

they had fever. Our pals in IM like them on all fevers- but indeed- ifyou do not have rigor or SIRS criteria- they may not be too helpful.

Cellulitis and pneumonia lead the way in being futile to take bloodcultures, where as septic shock is more useful obviously. This soonturns out to be a political struggle between us and IM but I always tell

7/27/2019 Emu Sept 2013 Part 1

9/23


my residents- - if you are going to take a blood culture on penumoniathen x ray his shoulder too- because you never if it is not broken. Howdo I know it isn't? Because it isn't. Period" ( JAMA 308(5)502) TAKE

HOME MESSAGE: Cellulitis, young UTIs pneumonia- do not bother with

blood cultures

7)Clinical pearls in dermatology- are they kidding? Who the heck

understands derm? Just give it some Latin name, give a steroid creamand send them for a biopsy. No, really, here are their pearls- good

luck! Recurrent erythema multiforme- should make you think of a HSVinfection give them acylcovir. Strep throat can cause a rash thatlooks like red drops. This is not a drug reaction but rather guttate

7/27/2019 Emu Sept 2013 Part 1

10/23


psoriasis which the strep causes to exacerbate. Phototherapy may beenough. Hard skin in the neck area- if the patient has DM,paraprotinemia and strep infections- think scleroderma. Now here is

the part of this paragraph to ignore. Really I mean it. You can also seescleroderma in multiple myeloma, hyperparathyroidism, Sjorgen's ,

insulinoma, rheumatoid, and HIV. Other diabetes skin disorders:candida, diabetic dermopathy (brown spots), diabetic bullae,

necrobiosis lipoidica, acanthosis nigra, insulin dystrophy andxanthoma. Good grief- who cares? (Mayo Clinic Proc 87(7) 695) TAKEHOME MESSAGE: You aren't going to catch these rashes, but keep in

7/27/2019 Emu Sept 2013 Part 1

11/23


mind the things that go with

them8)You thought you should skip the last paragraph- boy this is really

going to put you sleep. P values really are not that good. They can be

influenced by many things. First of all what is a p value? This ismeasure of how much the data obtained does not match with the null

hypothesis. Usually less than 0.05 is considered being no correlationwith the null hypothesis. However, multiple hypotheses, data dredging(going back to the data and trying too extract conclusions from the

data when the experiment wasn't designed for this purpose) small andlarge sample sizes can exaggerate the results. If the null hypothesis is

7/27/2019 Emu Sept 2013 Part 1

12/23


erroneous or ridiculous, the p value loses its value. You know what ismuch better? Confidence intervals- is the 95% chance the true datapoint occurs in between these two values is the best correlation.

(Osteoarth Cart 20(8) 805)

This is a chart from the article that will help you understand theconfidence interval TAKE HOME MESSAGE: Confidence intervals are

7/27/2019 Emu Sept 2013 Part 1

13/23


more reliable than p values. Oh

YAWN

9)Oh, I do not know- why are you even asking me? I do like bashingPPIs and we do know they cause calcium to be poorly absorbed

resulting in more fractures. I guess the same could be said formagnesium and indeed this study says that. ( Aliment Pharm THer

36(5)405). However, it could take anywhere between 14 days and 13years of therapy to occur and resolves fast upon discontinuation of the

therapy. In addition this is a meta analysis of small studies and asalways the question is are these studies comparable and where theycontrolled. As most of these were case reports I do not know if you

7/27/2019 Emu Sept 2013 Part 1

14/23


can conclude much, but what I would say is- use PPIs for short termand give those H2 blockers another chance. TAKE HOME MESSAGE:PPIs may cause

hypomagnesiumia

10) Just a bone for our naturalists out there. Colds in kids- we knowthat OTC and prescription cold medicines do not work and/or have

serious side effects. Echinacea and inhaled steroids also do not work.Vapor rubs, zinc (maybe- we discussed this in the past), buckwheat

honey and germanium extract seem to help symptoms. Prevention you can use probiotics, zinc, saline washes and the herbal prepChizukit (contains Echinacea, propilis and vitamin C). In adults none

7/27/2019 Emu Sept 2013 Part 1

15/23


of these really are that effective although garlic may reduce theincidence of colds (maybe because everyone who is sick will stay awayfrom you) Hand washing will reduce the spread of germs (Am Fam Phy

86'(2)153) If you ask me- none of this is too impressive except handwashing. TAKE HOME MESSAGE: Wash your hands to be URI cold free.

On a related subject- the mean cough duration in a URI is 18 days long after the patient feels better already. Please do not treat these

folks with antibiotics. (Ann Fam Med 11(1)5) Another bone for my treebark eating doctors- they did a multi centered, randomized blindedstudy of acupuncture in low back pain and it was no better than

placebo (Pain 153(9)1883). Could it work for something else? Not sureas low back painers are tough cases in any cases TAKE HOME

7/27/2019 Emu Sept 2013 Part 1

16/23

7/27/2019 Emu Sept 2013 Part 1

17/23


HOME MESSAGE: We can do more to reduce post LP headache andgive reasonable treatments for it. We just must get everyone to read either the Danish Medical Bulletin or EMU. In my opinion- you are

better off with the former. Especially if you like blondes.

12) And now let's travel a little north to view some more blondes inthis Swedish study. They took all these women with pylo and gave

them either two weeks or one week of Cipro. Guess what? Seven daysworked just as well as 14 (Lancet 380(9840)464). Couldn't find much

wrong with this study, and we do know that long durations ofantibiotics just increase resistance- This kind of reminds me of BLS- hitthem hard and fast. My question is do these folks if they do not

look terrible- really need to be admitted since treatment was oral?Seems for the literature that the answer is- no. Of course- perhaps

seven days may be too much as well. TAKE HOME MESSAGE: You cangive oral treatment for pylo for seven days and that is enough.

7/27/2019 Emu Sept 2013 Part 1

18/23


Speaking of blondes and Swedes- do you recognize this signing groupwho cranked out Dancing Queen, I do I do I do, Fernando, and SOS.

13) I certainly use dexamethasone for migraines that come to me-but they only work in 10% of patients perhaps some more in higher

doses. It is however, well tolerated (Post Grad Med 124(3)110)However, I do not believe this works on the short term, and this all

depends how long the patients were followed. However, a similarmetaanalysis AEM did back in 2008 (15(12)1553) was more optimistic.A randomized although small trial in 2011 found though that it did not

work (JEM 40(4) 463) but again there may have not been enoughfollow up. TAKE HOME MEMSAGE: Dexamethasone is not that great

for migraines, but it is well tolerated. My experience is that it does

7/27/2019 Emu Sept 2013 Part 1

19/23


work, and the studies are not great.

14) Yes, a definite maybe- after all, these are orthopedists writingthese articles. In clavicle fractures; kids always remodeled well, adults

a lot less- in any case there is a big movement now to surgically fixdisplaced fractures especially in adolescents ( J Am Acad Ortho Surg20(8)498) Are these just surgery happy orthos? Hard to say. Malunion

is for real but is it a functional problem? How much displacement? Myadvice- consult. TAKE HOME MESSAGE: Clavicle fracture which are

7/27/2019 Emu Sept 2013 Part 1

20/23


displaced may benefit from surgical repair- who gets an operation isn't

clear.15) In my shop we are expected to start ticagelor this stuff is

supposed to reduce cardiac death and MI. There were significant

questions about the efficacy and the safety of this drug (it is blackboxed in the USA) (especially the PALTO trial) and as such thestatistical reviewer and the cross discipline leader of the review team

recommended against FDA approval. (Cardiology 122(3)144) Why it

7/27/2019 Emu Sept 2013 Part 1

21/23


got approved is a good question and may be an ethical one as well(industry pressure?) but why should we EPs give such a drug with ablock box for bleeding when it just may not be better than clopidgrel?

TAKE HOMEMESSGE: Brillinta- when compared to Plavix- doesn't

shine16) You should have known this. Benzos really have few indications

other than for seizures. Mood disorders and anxiety maybe, but

SSRIs are better in the long term and in the short term clotiapineworks well. Benzos are also not the best bet for sedation (I likepropofol) and also not for intubated patients. Valium seems to be

7/27/2019 Emu Sept 2013 Part 1

22/23


immunosuppressive, and has a relatively long half life (don't let themfool you- so does midazolam due to fat redistribution). Oversedationand undersedation are common and benzos cause a lot of delirium.

They weaken respiratory muscles and increase ICU time. Alternatives?Remifentanil, dexedotmidine and propofol do not cause delirium and

have shorter half lifes ( Chest 142(2)281). TAKE HOME MESSAGE:Benzos are not really the best bet for a lot of things we used them for

in the past

17) Will mention this one last time another randomized study that

shows that antibiotics are the way to go for appendicitis. Sure 1/4 ofthe patients in this study ended up go to the OR and another 11% had

7/27/2019 Emu Sept 2013 Part 1

23/23


a recurrence within one year, but giving antibiotics is much safer thanoperations

Emu Sept 2013 Part 1

Documents

Transcript of Emu Sept 2013 Part 1