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FEB 12 1) Generally we do not bring a lot of articles from the Annals of Emergency Medicine, but I have affection for industry studies that turn out negative. There is a point of care device for measuring hemoglobin concentration but when compared to the standard lab device it didn't do too well. The difference averaged 2 gm/dl meaning that 13% of the patients may have been sent for transfusions that they did not need. (Ann Emerg Med 57(4)330) That is not to say that there is no need for the device in the ED, but the CBC is such a fast test in the lab that an expensive point of care device adds little to our practice. Perhaps in the clinic…While we are in this prestigious journal (you can try your best to guess if I am being sarcastic or not) there is a case report where they had a tooth avulsion and they returned it immediately (which is what you should do- do not scrub these teeth clean) and they anchored it in the socket with Histoacryl and the metal nose bridge from a non rebreather mask. Often even if you sew up the socket you do not always succeed in keeping the tooth anchored, but EM RAP recently mentioned that histoacryl gets dissolved by the saliva so it won't hold. I am not aware of any research on the topic, but in the ED when may not have any other choice- if it holds even for a day or two that may be enough. (ibid 57(4)375). TAKE HOME MESSAGE: Point of care testing for hemoglobin is not yet technically feasible and you can try superglue and any metal you find in the ED to anchor a tooth avulsion 2) We have really not spoken about this much but there is a concept of doing a triple rule out with a CT. What is the triple? This CT is used to look at the coronaries, the aorta (dissection) and the lung vessels (pulmonary embolism). The problem is that this is exposure to contrast, and the technique works differently for each study so there is a lot of radiation exposure. Furthermore there are still lots of questions as to the specificity of CT for coronary disease. This article just describes the technique but correctly warns- at this time- this is not to be sued as a routine screening tool (Card Rev 19(3)115). TAKE HOME MESSAGE: Triple rule outs are not ready for prime time 3) I am just taking one fact out of this article which I didn’t find to be overly relevant and that is that the most abused drugs in the USA are –first Alcohol, second- marijuana (I know, I know you don't inhale) and number three- a surprise- want to guess? (JAMA 305(13)1346) 4) I gotta admit, I never heard of this, but I am more intelligent now ( I know, there is little chance that this made me any more intelligent) but you know from reading EMU that a supra condylar fracture of the elbow is a bad fracture that can lead to neurological and vascular embarrassment ( how do you embarrass a nerve?) In any case, they report on 7 cases of well perfused pink pulseless hands after non surgical repair for these fractures. Most of them recovered their pulses after six weeks. ( J Ped Ortho 20(3)124) Not sure how this is relevant to you, but a case like this could walk in to your clinic or ED. TAKE HOME MESSAGE: Supra condylar fractures can cause vascular and neuro impairment, but if the hand is pink, do not worry about the pulses being absent. 5) Are you old enough to remember Vick's Vapo Rub? They rubbed that stuff on my chest when I was a kid – the thought was that this stuff full of menthol camphor and petroleum jelly would warm up the chest and cause the bronchi to open up and make coughing easier. Parents reported that this did a lot of wonderful things like improved cough less congestion and better sleeping. However this was not an intention to treat trial and also there are no objective parameters to judge if this really worked. (Peds 126 (6) 1092) I can not say if this works but it did do a job on chest hair. TAKE HOME MESSAGE: Menthol rubs have not been proven to help chest colds. 6) Maybe there is one reader out there that did not know this but if a kid swallows a foreign body and it passes the gastro esophageal junction- it will make it to the anus- doesn't matter if it is sharp or big ( PEC 27(4)284) 7) I am a big fan of Steve Selbst's Legal Medicine cases column, and he presents a case of 29 year old male who collapsed on the way to catch a train. In the ED, they did a drug screen, CT, EKG and chest film- all normal-discharge diagnosis was a possible seizure. The patient then collapsed again and died. There was no cardiac reason found on autopsy. What caused the guy's demise? Unlike most cases, the plaintiff did win this time (PEC 27(4)351) 8) I do not know who this will help, but right sided diverticulitis did as well with outpatient antibiotics as in admitted cases in this unusual Korean study where patients decided if they wanted to be admitted or not. You can really call this randomized. (World Journal of Surgery 35(5)118) It makes sense to me since most the pressures are lower on the right side and the danger of perforation is less. TAKE HOME MESSAGE: Diverticulitis on either side can often be treated as an outpatient. 9) Electrical storm- do you know about this disease? This is three or more spurts of VT, or appropriate discharges from an ICD. It is usual found in those with structural heart disease, congenital arrhythmic syndromes and those with an ICD. Amiodarone and beta blockade can be helpful but often radio ablation is necessary and actually these patients do very poorly (Tex Heart Inst 38(2)111). I actually saw a patient who received a shock from his ICD every few minutes and we thought that it was a malfunctioning ICD and to be truthful, such cases can occur and the ICD needs to be disabled- but be careful in view of the above. OK, Yoav, I finally found something interesting for you- what do you say? Do I win the Arbel award for Emergency Cardiology excellence? TAKE HOME MESSAGE: Take ICD shocks seriously and send them to the EPS lab. My peer reviewer adds: I have treated this with benzos, seriously, it reduces the sympathetic tone see Electrical storm in patients with an implanted defibrillator: a matter of definition. Israel CW, Barold SS in Ann Noninvasive Electrocardiol. 2007;12(4):375 10) Propofol is being abused. You may have known about that from the Jackson case, but this article reports that health care practitioner abuse (the article was written by nurses- so it is not just physicians) is not uncommon. (Subst Use Misue 46(9) 1199) Should you lose sleep over this? If you are abusing propofol, you probably aren't losing sleep. 11) I don't know- they claim that intra articular lidocaine works just as well as sedation for shoulder dislocations with obviously less dangers (Cochrane 4:4919). I don't know- I have had less success with intra articular injections, but maybe it is just me. Anyone out there with more success? Of course the other problem is that negative intrarticular lidacoine studies are not likely to be published. 12) This is my opinion, so you can skip this if you want- but why would you want to? Motorcycles in the USA are a lot less popular than they are in Israel and other foreign countries, and while most countries have a mandatory helmet law, some states in the USA have repealed their laws because of pressure from bikers. No one disputes that that motorcycle helmet use has resulted in less mortality and traumatic brain injury. However, opponents of the law claim that the torque on the neck is more likely to cause costly cervical spine injuries. This study showed that they do not cause more cervical spine injury ( JACS 212 (3) 295). The problem is that this is a retrospective study that looked for cervical spine injuries in a data base and found that helmeted riders had less C spine injuries than non helmet wearers. This doesn't take in to account how serious the traumas were, and what type of trauma they were. So yes, it doesn't prove anything. Then again, how did opponents convince anyone that it did cause more injury? And American football players have perhaps the worst designed helmet and these do not seem to increase the incidence of neck trauma. Indeed a study in the Asian Pacific Journal of Public Health (23 (4) 608 (We'll use the old Sid Cesar line "Stop me if you have heard this one before") showed that there is a difference between neck injuries seen in frontal impacts (they had less neck injuries) rear impacts (more neck injuries), skids(more) and side impact ( more). Again a poor retrospective study. TAKE HOME MESSAGE Helmet laws have reduced brain injuries- neck injuries are not as clear. 13) A lot of statistics here that make this seem worse than it may be, but do not forget that anticholinergic medications- like ipatropium bromide inhalations, antihistamines. TCAs and over active bladder agents can cause urinary retention especially in men with BPH- usually in first time users. They say the risk goes up to 40% but this is an odds ratio in a nested cohort so it is a percentage of a percentage. Furthermore, I am not sure how they enrolled patients to the database. (BJU Intl 107(8)1265). Another study from Arch Int Medicine 171(10)914) showed similar results with less patients but the methods were almost identical. However, anticholinergic medications can also cause significant confusion among the elderly. See also J AM Ger Soc 59:1477. TAKE HOME MESSAGE: Please be careful with use of anti cholinergic medications in the elderly. There are very few times you really need to use them. 14) I do not drink coffee or tea, but there are some who live on the brew (Alex are you reading this?) and even if you have VT in your past you can happily imbibe this stuff because the pro arrhythmic affect of caffeine is only seen at much higher dosages than most humans can bear. (AJM 124(4)284). Now is our problem keeping you awake or keeping you sober? 15) The pendulum swings yet again. We loved rate control although patients probably didn't- last month we mentioned Ian Stiell did not believe in rate control and this article adds to this. The problem has always been that the rhythm control meds that we have are not that effective nor safe- but if you could get a patient into to sinus rhythm and keep him there without side effects the evidence does suggest they have less morbidity and mortality ( J Gen Int Med 26(5)531) Indeed all of us have had patients like this that stay in sinus for a duration and actually are thankful for the quality of life they now have. 16) Remember the pendulum in the last paragraph? It just bopped us in the head –this paper says that dexmethasone in community acquired pneumonia that did not require the ICU reduced hospital stay and presumably they do better. The problem is that the study's methods were remarkable good. (Lancet 377(9782)2023)I read all the correspondence on this and I have a few comments of my own. Most of them agreed that the methods were fairly good. However, some folks from Shaare Zedek commented that dexmethasone causes faster defervesce so these patients may have been discharged erroneously since lack of fever is often a reason for discharge. Also clinical outcomes were not measured- only the shorter hospital stays. How many of these were old people discharged in poor condition back to the nursing home? How many were moved to the ICU after worsening- all this is not clear. And perhaps most importantly- can this be used in the community for patients with pneumonia not needing to come to the hospital? Steroids have not really proven themselves in any infectious disease so I am skeptical but then again I always am. 17) Clinical exam is the way you practice medicine- or is the way you should practice. Lab tests are to confirm your thoughts. This is what I think. So when studies such as the one from Archives of Dis of Child 96(5)440 appear, I get disenchanted, disappointed, disenfranchised, disemboweled and frankly just dissed. They looked at markers for serious infections. On the positive side, they considered serious bacterial infections and only one was bacteremia. The rest were what all of us would consider serious. On the negative side- all markers- pro calcitonin, WBC ANC, and CRP did better than the clinical exam. So now where do we go? The key is the area under the curve was used to compare these markers. I have little experience with area under the curve so I pulled the panic button, and sent an emergency e mail to Prof Hoffman from USC who is probably the best dissector of the literature who exists. And indeed he saved the day. Here is what he has to say: (if you want to know what area under the curve is, see Wikipedia- I have hyperlinked it for you)
so this is worse than silly. what we need to know is sensitivity for "bad," and (to a lesser extent, depending on the particular problem) specificity for "not-bad." asking a doc to say "% chance of bad" is ridiculous -- if he said "sure -- 80% likely," and was absolutely right (the kid turned out to be "bad"), he only got credit for an 80 (under the curve) ... even though he'd surely have done the right thing. likewise if he said "quite unlikely -- only 20%."
for the labs, btw, i don't care at all how "accurate" they are in isolation -- and none of these was nearly good enough, btw, as every one of them would miss at least 20% of the sick kids (unless you used a cut-off where virtually every # is called positive. what i want to know is do they help me change any clinical decision, and if so, how often is it for the better, vs for the worse. this study never asks those questions, nor does the available data allow us even to make a guess as to how they would have been answered.
best, jerry TAKE HOME MESSAGE: Markers are still probably not better than exam. Use them to confirm not to make diagnoses 18) You are not going to make this diagnosis not matter what you do and yes this could come to your clinic or your ED. Pre eclampsia- well you know that one- protenuria, hypertension, seizures perhaps, headache, absent reflexes. You also know that birth usually takes care of the problem. However, perhaps you did not know that this disease can present even after birth- and you may not see all the symptoms mentioned above (J Emerg Med 40(4) 380). Now that is the real problem. Headache after birth can be normal, or a bleed. Or from hypertension or from excess fluids. Edema can also be from excess fluids. Or post partum caridomyopathy. The treatment remains magnesium (ibid 25(4)387). TAKE HOME MESSAGE: Edema or headache in a post partum patient up to one month later can still be pre eclampsia. 19) Speaking of missing diagnoses this is another you will miss- septic arthritis. Great if you have an ultrasound, even better if you know how to use it, and even better if you can tap the joint. Most of us try doing ESR or CRP or WBC to help us out. They can help if you set the cutoff for CRP at greater than 20 (reasonable) and ESR at greater than 10 (that doesn't help at all). ( ibid 44094)428). The problem is that these are very non specific, and in truth most of us use all three together and hope for the best. TAKE HOME MESSAGE: Sed rate is really a bad test for septic arthritis. 20) Teaching procedures with residents being supervised by a mentor is actually comforting to patients Patients did not feel like guinea pigs but rather felt reassured. (J Hosp Med 6(4)219) No word how they felt if the mentor was unable to do the procedure either. 21) This is 18 pages of a lot of speculation but it is doubtful you will find much more on the subject somewhere else. The bulging of the inguinal ring in the athlete's groin has resulted in a new entity- since 1980 called the sports hernia. There is no room this month to go into this deeper and we already have our essays for this month, so if you are interested in this area (sorry bad pun) see the article (Clin Sports Med 30(2)417). In the same area of interest, is the prostate and prostatitis can be painful. This review goes over alpha blockers, bioflavinoids and anti inflammatory therapy but the only meds that definitely work are flouroquinolones. The others may be worth a try and they also mention electrical acupuncture and a possible remedy. Like most of my female readers I have had enough of speaking about men, so let's go on to another subject. TAKE HOME MESSAGE: Quinolones are the only proven therapy for prostatits. 22) I know I have missed this in the past and it was at a hospital that I did not have the assay. Psychiatric patients often come in lethargic. The differential can be pretty extensive. If it is an elderly patient, so all sorts of medication misadventures can be the cause. If it is a suicidal patient you have all the overdosages. If it is a drug abuser- and many are- you have these problems to deal with. Neuroleptic Malignant Syndrome can happen with any antipsychotic- even the newer ones, and Seritonin Syndrome can look just like this as well. Catatonia can be a cause all by itself. Never forget hyponatremia and sepsis. What I want you to remember is lithium toxicity. Yes I know that anti seizure medications have largely replaced lithium for bipolar disorders, but Lithium is still around. (South Med J 104(5)371) The treatment is dialysis and this should not be put off. There were some thoughts that K exylate might help since potassium and lithium are chemically similar, but since we have reported doubts on if kexylate works (see EMU from three months ago) this treatment is currently not accepted. TAKE HOME MESSAGE: Be very careful with a lethargic psych patient- consider Lithium toxicity. 23) This may be a helpful article to some one- but in truth, I f you are a parent you already know most of this. The article dealt with infants who cry too much. The statistics are fun also. For the first six weeks of life, children cry an average of 110-118 minutes a day. By 12 weeks this is down to 60. Basically, the chief causes of excessive crying are feeding difficulties, lactose overload, infection and allergy to foods, usually cow's milk. It is important to point out that reflux is not a cause. (BMJ 343:d772) I think all EPs and FPs must consider strongly other emergent causes in babies nod this article written by a GP form the Clinic for Unsettled Babies (wish they had the same for teenagers who complain too much) doesn’t mention them. Think also abuse, head injury, fractures, and of course the hair tourniquet on the fingers, penis or toes. Think also fissure, constipation and corneal abrasion- which is really common. TAKE HOME MESSAGE: Excessive crying is not from gastric reflux- consider the above causes. 24) Humiliation commonly occurs among patients- the gowns that open in the back and the uncomfortable exams in front of a large number of people. This article not only considers that but also the humiliation of medical staff and trainees. This article quoted "nursing faculty eat their young". What is really surprising is many of those who humiliate do not even realize they are doing it- they claim they are just being honest or that the circumstances required this behavior. If you are guilty of humiliating people will respond to sincerity and an expression of remorse and empathy, very few want compensation or to see the offender suffer. (Chest 139(4)746) If there is one article you read this year- this should be it –especially if you are a surgeon and know how to read (Was I just guilty of humiliating?) 25) This was a very basic paper on diabetic ketoacidosis treatment, and it describes the British protocol for treating this. What is new is that you can now check beta hydoxybutyrate at the bedside and this makes for easier following of the regression of the problem as opposed to the old way of following glucose. They recommend 15 units of insulin in a drip per hour since there are a lot more insulin resistant patients around including pregnant and obese people. Kids should be rehydrated slower than adults because of the development of cerebral edema, but they are not sure why this happens or even if there is a relationship. No need for insulin boluses. Lantus or Levemir should be started early; right after the IV insulin is discontinued. Bicarbonate and phosphate are not indicated unless there is profound muscle weakness, (Diab Med 28(5)508) See also Clinical Med 11(2)154) 26) I remember the night well. It was a winter evening in Blodgett Memorial Hospital in Grand Rapids Michigan way back in 1992. A body builder came in complaining of pain in the arm. We chalked it up to a muscle strain. A few days later, Dr. Pepper (not his real name) – my boss- got angry letter about a missed upper extremity DVT. After listening to an angry tirade for 20 minutes I respectfully pointed out to him that the patient came back two days later and was discharged by a physician that also missed the DVT. That doctor was none other than Dr. Pepper himself. But it is an easy diagnosis to miss especially if it is a primary DVT. Primary DVT is called Paget –Shroetter syndrome and is common in vigorous upper extremity activity or as a complication of thoracic outlet syndrome. Secondary is a lot more common and one cause not to miss is the CVP as a cause. Now why this is a hard call? You can see edema, yes, but pain is in less than 50% of patients and may even be as low as 30%. Erythema is present in only 15% of patients. 5% have no symptoms at all, but then again the same percentages of lower DVTs feel nothing. Only 34% of patients have thombophilia. D Dimer may not help even if it is negative and while ultrasound does make the diagnosis, Doppler does not add to the accuracy. You do not necessarily need to take out the catheter if that is the cause (if it is not infected) which seems odd to me. But that is the recommendation of the ACCP. Treatment is the same. Danger of embolism is somewhat less (AJM 124: 402) TAKE HOME MESSAGE: Upper Extremity DVT is a tough call and many identifying features may be absent. Otherwise treatment is the same as for all DVTs 27) We didn't forget – number #3 above – the third most abused drug in the USA is hydrocodone. I was surprised. But in view of the drastic increase in pharmacy robberies with many tragic consequences (the Father's Day Massacre in Long Island was one grisly example), we need a solution to this problem- and quickly 28) And number seven above was a pulmonary embolism. Tough calls always but keep it in mind in patients with syncope. By the way the one who missed this was not me. It was Dr. Pepper. 29) Big believer in vitamins? Did you miss the article on vitamin E increasing the risk of prostate cancer? Now you can't say you didn't. Also it caused more hemorrhagic strokes and heart failure (JAMA 306 (14)4159. Looks like you can throw away your leisure suit and hot comb now ( if you don't remember these – ask your grandparents) EMU LOOKS AT:LOLLIPOPS Kids suck on lollipops so we will at long last have our roundtable discussion on peds issues. Adults suck on a different type of lollipop- usually one that is hollow and looks like this: It comes only in one flavor- lidocaine gel flavor. And that is the subject of our first essay. You know how to put one of these in but what do you do once it is in and the nurse asks you for parameters? Or the patient crashes? The source of this essay is JEM 40(4)419 and ibid 37(28)s23. The former was written by Mike Winters who I have heard speak on EM RAP- he was excellent; the second was written by good friend Barry Brenner (an EMU reader) and Antoine Kazzi who I met when lecturing out at USC many years ago. 1) I guess we have to start at sedation, and we have spoken about this often in the past. Just don't be a jerk and give paralysis without sedation. Think about it – the t 1/2 of most paralytics is beyond many sedatives. Sedatives weaken muscles and make extubation harder and therefore the move right now is to sedate with opiods. If you need a sedative- consider the following: midazolam accumulates in the tissues, is renally excreted (a problem in low flow states or ARF) and has an active metabolite so in long infusions can make your patient overly sedated and weakened. Lorezapam is hepatically metabolized, so that is better, but long infusions can cause delirium and propylene glycol toxicity. Propofol therefore is now the choice sedative but there is the well known propofol infusion syndrome if given for long periods of time. Indeed paralytics can cause myopathy so try to get them off as soon as possible. In a rapidly breathing patient who I just intubated, I sometimes paralyze just to give him a rest, however this requires a caveat. If this is a metabolic acidosis you must correct the cause and set the vent settings to allow for compensation (hyperventilation). On the other hand if this is pneumonia- paralyzing means you really have to be doing adequate pulmonary toilet. In other forms of respiratory failure it is reasonable. 2) Now you have this machine in front of you with lots of dials and buttons and what do you do? I can't tell you what they are all for and how much sigh you should give, but there are some basics that you have to know. First and foremost- you want to protect the lung from ventilator injury which occurs in four ways. Volume trauma comes from overdistension of the lung units. Barotrauma comes from air that dissects along fascial planes. Biotrauma comes from inflammatory mediators that affect the rest of the body as well. Atelectic trauma is injury caused by repeated opening and closing of lung units. The last one you can prevent by using PEEP- remember that physiological PEEP is about 4. Volume trauma can be reduced by using smaller tidal volumes. Use lower oxygen concentrations to avoid oxygen toxicity. In fact 25% of intubated patients develop ARDS or lung injury within 5 days of intubation. 3) How do we ventilate the patient? In the ED most of us use SIMV or A/C- the difference being of course that in A/C the patient gets a full tidal volume no matter what for every breath. While SIMV is more popular, often in patients that need to rest after breathing heavily I use A/C. COPD and asthma patients tend to have more air trapping with A/C- keep them on SIMV if they are still breathing. 4) So let's get practical. Tidal volume should be 6 ml/kg of ideal weight. It would be best to do this by checking plateau pressure and seeing that is under 30 but this is not easy for everyone especially if you do not have a respiratory tech. PEEP should be 5-7 but don't be shy in going up if there is pulmonary edema. You start oxygen at 100% but if the patient holds their oxygenation, your goal is to get below 60% if you can. Try going up on the PEEP while going down on the FiO2 if you can't keep the saturation up. If the pH gets below 7.15 you can increase the respiratory rate but it may not be necessary to keep checking pH as the capnograph can give us a lot of information. PSV of 5 -10 helps breathing patients breathe easier. It leads to better gas distribution, to less baro trauma and cardiovascular effects. But the patient needs to be spontaneously breathing. Flow rate is the amount that the patient has access to so make that at least 35. 5) How do you monitor the patient? Well pulse oximetry is the easiest way, but if there is hypotension, hypothermia or they are getting pressors the readings may be in accurate (although not clear to me how inaccurate they will be- it may be negligible). Capnography is a great help. It generally underestimates CO2 concentration by 2-5 mm which is fine for me. It can help to show ventilation status and also helps to show when CO2 levels are rising. In the old days they taught me to consider DOPE for patients that were not getting ventilated well where D is dislodgement, O is obstruction, P is pneumothorax and E is equipment failure. However with the advent of capnography things are now easier. If you suddenly lose the waveform think about obstruction, extubation, or cardiac arrest. A drop in the wave form that doesn't get to zero: think airway leak or hypotention. It also helps determine ideal PEEP levels and helps evaluate how weaning is coming along. 6) CVP is not really that useful for monitoring purposes. Mechanical ventilation is just one of the things that can affect its accuracy. However it is very useful in giving high volumes of fluids and also if giving pressors. You should however be careful about intra abdominal pressures because of abdominal compartment syndrome – this is measured by a probe in the bladder. Since the treatment of abdominal compartment syndrome is surgical and since PEEP and large amount of fluids can pre dispose to this, keep it in mind- the patient will not remind you. 7) Ventilator associated pneumonia is devastating, and while many times the diagnosis is made in the ICU the causes can be traced to the ED. Here are some tips- semi recumbent position helps reduce the incidence of this pneumonia. Gastric decompression helps as well. Washing hands before taking care of these patients, oral rinses with chlorhexidine, and lung protecting ventilator management all can prevent this prognostic poor disease. 8) Another strategy that will prevent pneumonia is not giving everyone stress ulcer prophylaxis. True 75% of patients get erosions within 24 hours of admission to the ICU, but true hemorrhage has an incidence only about 3-4%. If the patient is at high risk for hemorrhage- OK, but otherwise, the risks are too high for pneumonia as PPI can cause poor eradication of bacteria in the stomach. 9) Now if your patient is crashing, it is time to get to work. Firstly disconnect from the respirator and manually ventilate. Then it is time to go over the DOPE again with special attention to a tension pneumothorax. Suction the patient and inflate the balloon. Make sure the tube hasn't' migrated out of the trachea e.g. in the stomach or found its way to the right main stem bronchus. Check you ventilator and see that it is getting oxygen and delivering it. NEVER and I mean NEVER ignore alarms on the ventilator- they are there for a reason. 10) Auto PEEP should always be thought about. This is due to incomplete exhalation which causes increases in thoracic pressures and possible cardiac collapse. This is most often seen in COPD and Asthma but it can occur in anyone with large tidal volume and short expiratory times. The treatment is lower the respiratory rate, lower the tidal volume or changing the inspiratory to expiratory ratio; that is you want to lower this ratio. Sedation is imperative also as well as broncho dilators and steroids for asthma patients. 11) Cuff leaks are easy to identify – listen for noises that shouldn't be heard like groans and whistles. Also if the tidal volume is not coming close to the set tidal volume this may be the cause. 12) If you are a pro you have some other help. Ultrasound can detect a pneumothorax by the sliding lung sign. Checking peak pressure can tell you about airflow resistance such as obstruction or bronchospasm and increases in peak pressure can indicate problems with compliance. If both go up, ARDS, Pneumonia, or abdominal distension should be considered. The treatment of course is to correct the underlying problem 13) Now to the article on asthma-Barry this was an excellent article on the special case of the intubated asthmatic. You do want to avoid intubation if at all possible in these patients because they do poorly. There are many therapies that in addition to steroids, beta aerosols, epinephrine and magnesium that you may want to try to avoid that tube that have been less proven. Heliox, nebulized clonidine (never hear of that one) nebulized calcium channel blockers (ditto), nebulized lidocaine (not a lot of luck with that), ketamine, and glucagon. IV lidocaine doesn't help for anything. Remember that mild hypercarbia alone is not a reason to intubate an asthmatic( he may respond to your therapy) and not a reason alone to intubate COPD er for that matter). (BiPAP is a good option here) In fact you do not need ABGs at all. (I believe that VBGs are not that helpful here either- just look at the patient and make your judgment that way.). 14) He believes we should give atropine IV and lidocaine sprays to attenuate larynogspasm; I am not sure why this should be more of a problem in an asthmatic. 15) He then speaks about sedation- we will not go over this other than he says that propofol has bronchodilatory effects- which I did not know. Morphine and Succyncholine are not supposed to be used because of histamine release, but Barry doubts this is clinically significant. 16) He mentions also the crashing patient and Auto PEEP. Again-lower the respiratory rate which is the most effective way to deal with it. The try to increase the inspiration flow rate- 60 is a good number. Do not let hypercarbia worry you- they can deal with Paco2 of up to 90. 17) Probably a good idea to avoid PEEP above 5. Avoid paralysis as well which can worsen myopathy especially with use of steroids which most are receiving. 18) You can give breathing treatments to an intubated patient by simply applying an MDI. EMU ROUNTABLE:PEDS ISSUES We have five questions this time, and the roundtable was honored to get some of the bigger names in Peds EM. Let me introduce them: We have Al Sacchetti, a perennial speaker on EM RAP and at the ACEP Scientific Assembly. He hails from Our Lady of Lures Hospital. Kevin Schreiber is double boarded in both Peds and EM, and works here in Israel. Zach Kassuto is a Peds EP from Drexel University in Philly (Al and Zach- do you know each other?) Let's get started here is the first question: Al Al begins: Zach:
Kevin Minor head trauma
There have been many articles in the last several years with indications when imaging is recommended for head trauma.
Al, you get started. Zach: Cough is a common ED complaint and is very frustrating and worrisome for parents. When presenting to the ED for cough one usually finds disconcordance between parental concerns and physician concerns. As ED physicians we are thrilled when we can tell the parent that the child does not have pneumonia, pertussis, foreign body, etc. But the parent’s agenda often is not only the diagnosis but the symptom. They want you to stop the cough (this issue also comes up with the issue of treating fever, perhaps a question for a future round table). It has been known for years in pediatric academic circles that cough cold medications offer little if any help to relieve this symptom and that there is a small but very real risk (including death) for the patients. The AAP has long opposed the use of codeine and dextromethorphan, but this did not stop US drug makers from producing a huge variety of over the counter (OTC) cold medications. Also, for years US physicians have liberally prescribed cold remedies despite the organizational recommendations. More recently the US Federal and Drug Administration came out against the OTC cold medications in children under 2 years and the drug manufacturers then “voluntarily” withdrew many preparations from store shelves. Following the FDA directive I have noticed some movement away from the routine prescribing of cold medications in the pediatric medical community (community and academic practitioners), but the parents continue to ask for (at times demand) treatment and they often walk away with the perception that the doctor did not do anything since they do not have a prescription in hand. It is relatively easy for me as a single encounter ED doc to decline such requests and try and reassure/convince the poor worried parent that this too shall pass. I pity the poor primary care practitioner who must deal with the ongoing (sometimes daily) calls from concerned parents complaining about an ongoing cough. My focus in the ED remains to consider the cause of the cough, and consider treatment of common treatable causes such as allergies or reactive airway disease if these seem relevant. There is some literature worth looking at that suggesting various alternative treatments for cold symptoms (e.g., honey in older children, etc.). In general, I do not recommend OTC or prescribe cold medications regardless of the patient’s age. Kevin:
The Nighttime Cougher
This is a problem that plagues every parent and pediatrician alike. I am truly not advocate from pharmacological intervention in this age group. I have many colleagues that do medicate, but have has seen several cases on severe side effects (SVT) from these medicines. There was a study done comparing honey to the pharmacological agents for cough showed that honey outperformed dextromethorphan (Archives of Paediatric and Adolescent Medicine, December 2007). For this reason in kids older that 1 year of age I recommend honey 5cc BID. Besides this I recommend the basics: NS nose drops, humidifiers/ vaporizers, and elevating the head of the bed. I am still eagerly awaiting the individual who will be rich by inventing a good cough medicine for these children with a good safety rating. Guess who just showed up? Lisa Amir- she is double boarded in peds and EM and is the assistant director at Schnieder Hospital ED here in Israel. She also has an MPH and is quoted often in EMU because she is a great friend and brilliant to boot. Here is her comment: . URTI and cough symptoms in children Already in the early 90's randomized, placebo controlled studies were demonstrating that antihistamines, dextromethorphan and codeine were no better than placebo for treatment of day and nighttime symptoms associated with URTI in children. Several studies even specifically looked at parental quality of sleep as an outcome measure and failed to find any benefit. Readers who would like a concise but thorough review of the subject are referred to Expert Opinions in Drug Safety 2010 9(2): 233-242 or the Cochrane review from 2008. Of note, the American Academy of Pediatrics back in 1997 advised against the use of codeine and dextromethorphan containing compounds in children. It has taken the FDA a few years to catch up.
The toxicology literature contains a number of case reports and case series of young children, particularly under the age of 2, suffering side effects from these compounds, ranging from mild to fatal. In most of these cases, the parents adminstered OTC medications in the therapeutic dosage as recommended by the manufacturer. Given the lack of clinical efficacy and the potentially serious side effects, these medications have no role in the managment of symptoms in children less than 2 years of age, and probably under 6 years of age.
What to recommend to the parent who isn't getting any sleep? First, I make sure that the child is only suffering from URTI and not bronchospasm (in children this can manifest as a noctural cough without clear wheezing). Next, an explanation as to why we are not prescribing these medications. In my experience of not prescribing these meds, the majority of parents are willing to put up with a few sleepness nights once they understand that we really don't have an effective and safe alternative. Finally, I offer some practical suggestions: alternate nights between the parents, don't put the child in bed to sleep with you (no, your 18 month old really won't stop breathing but you will stop waking up every time he coughs).
Very informative. Now on to the next question
Al you are batting lead off. Zach says: This is a complex, multifaceted question that could fill pages of discussion.
Kevin says: FEVER In older children, blood tests are hardly indicated especially post introduction of the pneumoccocal vaccine. If there is a specific concern i.e. prolonged fever, ill appearing child C-Reactive protein or a procalcitonin (clinical significance debatable) can be useful at identifying acute bacterial infections, as opposed to other causes. Absolute neutrophil count if normal can be helpful but if elevated, especially in the presence of a high WBC count, does not bear much weight. In neonates what criteria to use is difficult. The Rochester and Philadelphia criteria are fairly similar and most physicians are using the temperature cut off at 38.0 and age less than 8 weeks. These criteria are being used more as a guideline in the older neonates, infants greater than 4 weeks of age. This is of course assuming that the examining physician has superior clinical skills. More and more doctors are trending not to do LP’s on all febrile infants above 6 week’s of age, but to initially do a CBC, blood culture, UA, urine culture, ? RSV, Flu? Then, after initial results are obtained, make a decision about the need for LP. Infants less than 4 weeks of age still should have a sepsis work up with admission and parenteral antibiotics. We're doing great; now to the fourth question:
Al replies Zach: In the settings in which I practice (community hospital peds ED and academic center/children’s hospital), we do rapid strep testing of children with suspected strep pharyngitis. If this is positive, we treat them with antibiotics. If the test is negative, we send a throat swab for culture. If the culture comes back positive, we treat the patient with antibiotics. This is in line with the AAP Red Book recommendations. Although our incidence of Rheumatic Fever/Rheumatic Heart Disease is low, the concern still remains.
Over to Kevin STREP
Working in an area where rheumatic heart disease is still quite prevalent, it is difficult for me not to treat every child that tests positive for Strep Pharyngitis by culture or rapid antigen testing. I see a new case of rheumatic heart disease every 2-4 months. With this, the risk of non treatment is far outweighed by the risk of rheumatic heart disease. I would like to add that when treating these children with antibiotic suspensions, I always prefer amoxicillin over penicillin secondary to palatability. I believe that one of the reasons for the large number of cases of rheumatic heart disease is that many physicians still prefer penicillin over amoxicillin. It is true that penicillin is more specific, but that is only true if the antibiotics are swallowed and the course of treatment is completed. As far as I am concerned, with strep treatment is a must!! Yosef: I'll just add a word of my own here. I practice also in an area where RHD is seen, although I must admit I never diagnosed it. I go by clinical features- although not sure I have much basis for it. What I mean is I do do a rapid test in folks with a sore throat even if there is a Center score of 0. But if it is negative, I am not a big believer in the throat culture being a gold standard especially if the clinical picture is lacking. I will take it if in doubt. If the Center score is 4, I just treat regardless without any test. Oh , here is Lisa one more time:
4. Positive throat culture This is an easy one. Why was the throat culture done? If the child had an acute febrile illness with tonsillopharyngitis but has clinically improved since the throat culture was obtained, he needs to be treated. Streptococcal pharyngitis is an acute, self limited illness - the kids will get better whether or not we treat. We just don't want them to get ARF.
However, if the throat culture was performed in a child who did not have a clear clinical picture, the indication to treat is less clear. A recent study (Pediatrics. 126(3):e557-64, 2010 Sep) demonstrated a streptococcal carriage rate of 12% among children less than 18 years who did not have pharyngitis. Since these children at not at risk for developing ARF or invasive infections and have a very low transmission rate to other family members, treatment is not recommended
My experience is that children do better with amoxicillin rather than penicillin. Amoxicillin can be adminstered as a single daily dose, 50 mg/kg to 1g maximum, hopefully increasing compliance and is more palatable than the penicillin preparations. In addition, adolescents do not like taking penicillin because it makes their urine smell bad (this may not sound like a significant side effect but they think it is). Penicillin allergic patients can be treated with a ten day course of narrow spectrum cephalosporin or azithromycin 12 mg/kg/d for 5 days. Uncooperative or poorly compliant patients can be treated with IM benzathine penicillin G (some parents and even children actually prefer this route). Remember - penicillin resistant by GAS has never been documented - there is no role for augmentin in the treatment of these patients.
Last Question
Al, what do you think?
Also see the 2011 Pediatrics article suggesting an association between acetaminophen and asthma (http://pediatrics.aappublications.org/content/128/6/1181.full.pdf+html). This article states: “Until future studies document the safety of this drug, children with asthma or at risk for asthma should avoid the use of acetaminophen.” Other studies are ongoing. Some question whether the association is between asthma and the medication, or asthma and the conditions for which the medication is being given. If we assumes that our prime directive is to do no harm, and the symptom that is being treated (in this case fever) if anything improves the immune response to illness, then why use the medication even if the risk is theoretical or small. One could argue for treatment with acetaminophen to alleviate the discomfort associated with fever (this reason is similar to the reasoning some use to justify treating cough/colds with cold medications). Another reason some treat fever is a cultural perception that fever is harmful and to help allay parental fears (see comments about cough medications above) And now, Kevin: ASTHMA Risk from antibiotics/ paracetamol
This is a new hot topic. Have we found the reasons for increased incidence of asthma worldwide? Firstly, there need to be more prospective studies examining this correlation. I am not convinced yet, but I am sure there will be many more publications on this matter in the up and coming years. The bigger question at hand is how we prove safety of medication profiles for the long term. If we are just finding new associations between paracetamol and illnesses, what medicines can we say are truly safe for any population? If this association turns out to be validated, we are entering a very hard time in the field of medicine. This has been a wonderful discussion; I thank our experts- (who are EMU readers) for donating their time for this endeavor. If you have other questions on any subject, let me know and we will make another roundtable!
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