Emergency Medicine Update February 2012

This is the fourth edition of EMU to be modified for LITFL readers. You can download the original pdf version here, which also contains an essay on mechanical ventilation and a round table discussion of hot topics in pediatrics. Check out previous editions of EMU on LITFL here.

If you’d like to subscribe to EMU directly send an email to: jbleibmd AT yahoo.com

Learn about the latest emergency literature by clicking on the show/ hide links below:

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

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 used as a routine screening tool (Card Rev 19(3)115 ).

TAKE HOME MESSAGE: Triple rule outs are not ready for prime time

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 )

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.

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.

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 )

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 )

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.

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

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.

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.

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.

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.

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?

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.

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.

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)

i deliberately chose not to do this study, yosef, when it came out. without going into detail, i’ll only say that no one makes a decision based on an AUC in clinical medicine — we use cut-offs — either one y/n cut-off, or a few of them (no- vs low- vs med- vs hi-risk, or to the OR vs do tests vs d/c, etc). even for labs with exact #s, like WBC or CRP or DD, we would (if we were foolish enough to get the test in the first place) do the same — it increases my worry vs decreases it vs has no effect — no one treats a WBC on a continuous curve, or thinks of WBC of 11.7 differently than WBC of 10.8.

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.

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 hyperreflexia. 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.

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.

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.

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.

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 Kexylate 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.

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.

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?)

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 )

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

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

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.

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).

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  1. james innes says

    “Pre eclampsia- well you know that one- protenuria, hypertension, seizures perhaps, headache, absent reflexes”…..should this read “hyperreflexia”…..end goal of magnesium treatment is loss of deep tendon reflexes..?!

  2. Stephen says

    RE: The swallowed foreign body. I can recall a case in our ED in the last six months where a junior called the nearest Paediatric Gastroenterology service before speaking to an ED senior. As a result the child received daily abdominal XR until a paediatric clinic review a week later .

  3. Jay Baker says

    I have two toddlers and disagree with
    TAKE HOME MESSAGE: Menthol rubs have not been proven to help chest colds.

    Ok, menthol rubs do nothing to cure chest colds. But when my wife rejects my “it’s only a virus” lecture and pleads for something to treat her babies’ coughs, I can give her something that doesn’t kill children and she feels like she’s finally doing something for them. That’s a big help.

    Although I suspect it doesn’t do much to kill viruses either, we also use honey for coughs. My kids love it.