EMERGENCY MEDICINE UPDATE
MARCH 2012
1) Can't take anything from this study on cadavers but it does go against myths that ATLS has given us and this in itself is worthy to mention. The recommendations of ATLS were always to log roll patients 90 degrees and then to slide the board out from under them while checking the back. This according to the authors can cause unacceptable neck motion. It is believed that maintaining in line stabilization is thought to cause less movement and therefore lifting the patient and sliding the board out is safer. OK well, this was cadavers, and who knows if the movement is significant but it makes some sense that it will be harder to maintain neck stabilization when revolving the patient.(J Trauma 70(5)1282). PLEASE REMEMBER- the spine board is for transport only and provides no stabilization of the spine. It causes back pain in normal volunteers for up to three weeks afterwards when left on the board for the usual time most EDs leave patients on these boards. Also can cause pressures sores. Take them off the board immediately. TAKE HOME MESSAGE: The log roll is not holy and may not be the best way to take the patient off a long board. But do get him off fast.
2) This study was surprisingly well done- what was it doing in such a obscure journal? They claim that NTPROBNP levels are high when A fib starts and then go down after 48 hours- how well do they predict left atrium thrombus? If they are good, then you can use this to convert them. Are you a family doc? Do the test, then give some Propafenone and you saved your patient time and money. In this study they took patients with no heart failure and a fib of unknown duration and did the test. It worked actually very well. (Heart 97(11)914) The problems- there were few patients in each group and even in the low values there were still 5% that had a thrombus so it isn't perfect. False positives aren't so important here because the absence of the NTPROBNP is what we are looking for. But like D Dimer it could be that this is rarely negative. Needs a bigger study. TAKE HOME MESSAGE: NTPROBNP is a new possible way of determining if there is a right atrial thrombus but it needs more study.
3) Good Grief- just when you thought it was safe to go out. Like my pals Rick and Jerry, I can't resist not including one pulmonary embolism article per issue and here we are (did we lose everyone yet? You in the corner- Why aren't you leaving? Oh sorry, didn't mean to wake you up) But this is an important one. There is an entity of non thrombotic pulmonary embolism which can be due to air, amniotic fluids, a variety of other gases and materials, infectious emboli, and fat. D dimer is often negative and CT can be unreliable. (J Thromb Thromb 31(4)436) Of course clinical picture will be very helpful here but little else – perhaps MRI? TAKE HOME MESSAGE: PE can be from other causes than thrombosis- and nothing much will help you with clinching the diagnosis. While we are at it we should mention the Lancet (378(9785)41) article about sending some PE patients home. I do not think there is any argument here the study was well done and the question is just- who qualifies? It is worthwhile mentioning that in this study no one died at home and even in the hospital only one died. Those who were sent home had category one or two PE which has a mortality of up to 10% but it is clear that probably more could have been sent home since so few died in the hospital.
4) OK, this month's clinical challenge is actually quite easy. This patient underwent a thyroidectomy. (CMAJ 183(8)e498)
5) I have an interest in flight medicine and this is a reminder that the air in the ET tube can expand when ascending. The numbers- if they are important to you are that tracheal mucosal perfusion is impaired at 30 cm H2O and by 50 total blood perfusion is impaired. The study used an in vitro model with ascent to 2400 meter which is less than most airplanes fly but it is what the cabin is pressurized to. Interestingly enough but not surprising from a physics viewpoint is that water filled balloons were unaffected. (PEC 27(5)367).TAKE HOME MESSAGE: In ascent whether they are to mountains or in planes- you must remove air from balloons that may cause impaired perfusion. Now the article that I wanted to do but never got around to. A dermatologist- of all folks, huh?- did a study to see if air lines in Europe were in compliance with international standards for required equipment for in flight emergencies. None were. A lot of them had weird stuff in their kits including IV aspirin and po placebo. (Trav Med Inf Dis 8(6)388) Now in deference to my Asian readers, EL AL, Qantas (leave off guys, I know Australia is not part of Asia) and Air India were not included in the study. These issues were also discussed in JAMA, 305(19)2003 and they found that flight attendants were ill prepared for in flight emergencies even thought the FAA mandates drills in use of the AED and CPR skills. Standardized recording systems for emergencies do not exist and while on ground medical support exists it is rarely used. TAKE HOME MESSAGE: Be prepared to not be prepared on in-flight emergencies.
6) An article that was just a survey of their center in dealing with nail bed lacerations but the important point here is that plastics repair showed no better results than EPs. I assume the same for FPs as well. This is a laceration- while ugly- that most of us should be able to handle- just be careful if it crosses the germinal matrix. (ibid p375). TAKE HOME MESSAGE: Everyone can sew nailbed lacerations pretty well with good results
7) A great idea and I am sure that the ultrasound geeks that read EMU are already salivating. For pleural effusions, pulmonary edema, pneumothorax and lung consolidation- ultrasound at bedside performed just as well as chest x ray (when CT was used as the gold standard). (Chest 139(5)1140) The kappa was 95% which is very impressive, although not clear to me why they used p values for some comparisons and Kappas for others. The study did not look at pneumonia and lung masses so you probably have to still do films for these conditions. TAKE HOME MESSAGE: Beside ultrasound can replace chest films for many conditions.
8) We discussed upper extremity PE in last month's issue. Here is some more data. 1% of these patients get PEs which is low for DVTs but 5 of their patients who were on Coumadin fell and bled in their brains and died. (Ann Vasc Suyrg 25(4)442) So do you treat these folks with Coumadin or not? Good question. No answer. There was referral bias in this study as it came from a DVT clinic but this doesn't ehlp us answer this question. TAKE HOME MESSAGE: Upper Extremity DVT needs Coumadin- or maybe not. Or maybe yes.
9) Fads come and go and I have to admit I was a doubter as to how important Vitamin D is. Recently the daily recommended allowances for Vitamin D have increased and we do know that is related to immune function. In this study, patients with sepsis who were vitamin D deficient did worse. They designed the study using APACHE scores, and SOPFA scores. (AEM 18(5)551). This study was not randomized and only had 81 patients, in addition APACHE score is just that – a score. Some patients may have been worse in some aspect of APACHE that may be worse in sepsis or in vitamin D deficiency or both- it is hard to tell. But yes, I probably will go out and get those vitamin D pills. Or at least take my intubated septic patients outside to get some good sun. TAKE HOME MESSAGE: Vitamin D deficient patients may do worse in septic shock. And yes, I did buy those pills
10) Adam Singer is our guest speaker for this year's scientific assembly. Adam is known to be a paper factory but the great thing about Adam is the originality of his research. Adam brought us a lot of the first articles on gluing wounds, and the article on the use of Docusate for ear wax and many others that I enjoyed. The originality continues- Adam found in a meta analysis that in four countries they sew up abscesses after opening them- which we do not generally do. They healed faster and had no more septic complications. Adam admits that most of this research was done on surgical patients by surgeons on anogenital abscesses but the studies were randomized and showed this works. (AJEM 29(4)361) The big question is that these studies came out of basically four countries- Nigeria, Australia, India and the UK- can it be repeated elsewhere? Adam is an EMU reader for years now, and I am privileged to have spoken to him on many occasions. However, if you are one of those salivating geeks I spoke about before- doing ultrasound guided needle aspiration of skin abscesses did not do as well as traditional incision and drainage. My first inclination was to say, that incision is always better than needle aspiration because needle aspiration is a dynamic process- it is to be done multiple times until the problem resolves. But that was not the point of the article- despite seeing the abscess cavity on ultrasound they frequently came up with taps that had no pus in them. (Ann Emrg Med 57(5)483) Really sounds like this is operator dependant. TAKE HOME MESSAGE: You can sew up abscesses that have been drained but if you use ultrasound to aspirate them, you may not be as successful as incision.
11) How about some more name dropping. EMU reader and peer reviewer in the past Prof Pinny Halpern has also appeared at our roundtables. They recently published a paper on the use of lidocaine jelly for the insertion of NG tubes (Zonde) versus KY jelly. While this is hard to be double blinded because the jellies do look different but indeed the lidociane jelly caused less gagging and less pain. However it was harder to insert the tube (AJEM 29(4)386). I discussed this with Pinny and this could be because the swallowing mechanism becomes anesthetized and therefore they can't swallow the tube or it could be that KY is more viscous and therefore spreads better and goes further down the GI tract. In either case in Israel we exclusively use lidocaine jelly, but in the USA the use is less common. Nebulized lidocaine is another option that Chris Nickson uses. Give it a try, Huh? TAKE HOME MESSAGE: Lidocaine jelly causes less gagging than KY Jelly
12) OK, I know you are smart. You not only get EMU, but you subscribe to EMA, read Life in the Fast lane and go up on EM Central. So you knew that the case above in # 4 was the Trousseau sign seen in hypocalcemia. But this case is tougher. A fifty year old man has an abscess of the appendix- He is previously healthy. He got cefotaxime and metronidazole in the hospital and was discharged with metronidazole and ciprofloxacin for continuing therapy. 5 days later he is found with hearing loss, vomiting, ataxia and dysarthria. MRI shows: bilateral and symmetric swellings of the cerebellar dentate nuclei, dorsal medulla, dorsal pons, midbrain, corpus callosum and increased signal intensity in the supratentorial periventricular white matter. PS- he was admitted to the ICU. Viral and bacterial cultures were all normal, as was the LP. What happened? TFTs and Autoimmune markers were also negative. If you are not an ultrasound geek but an IM geek, you should know the answer immediately. (Lancet 378(9787) 288), If you are both an ultrasound and IM geek, you should be writing EMU, not me.
13) OK let's say you are a pediatrician. And you think that despite last month's roundtable on pediatrics I do not spend enough time speaking about kids. So since you immediately knew that the case above was metronidazole induced encephalopathy, so I will give you one. Really not too difficult but I am surprised how many do not know about this condition. Age of onset- 7-12. Girls more than boys. Colicky abdominal pain, often incapacitating, with vomiting and occasional headaches. Nothing really has been proven as helping for treatment. Diagnosis please J Ped Health Care 24(6)372)
14) I won't drag things out- this one was pretty easy. And I didn’t know the original description of the entity goes back to 1986 (Cephalagia 6(4)223). This is abdominal migraine which is very similar to its head equivalent. You do need to rule out other causes of course.
15) ICU corner. These two articles in the same journal (CCM 39(6) 1562) and (ibid 1576) deal with refractory hypoxemia usually due to ARDS. The first article points out that with H1N1 we suddenly had a lot of patients with ARDS who did not have past medical problems and therefore rescue therapies could be tried, in contradistinction to the usual ARDS patients with multiple medical problems who generally die from multi organ failure fairly quickly. The first steps are usually PEEP and prone positioning, but now there are some new players to try- ECMO, which worked in 51% of the patients – a very high percentage of survival for this malady, but it resulted in blood loss. Other therapies include high frequency ventilation which is favored by the Canadians, and airway pressure relief ventilation . If you are not familiar with these therapies, I have hyperlinked you to Wikipedia and CCM tutorials. TAKE HOME POINT: PEEP is the standard for treatment for ARDS. ECMO is an exciting new option. Other therapies are very interesting but unproven.