• No
• The seminal vesicles may contract as part of rigor mortis, resulting in the expulsion of seminal fluid.
• Rigor mortis is the post-mortem contraction of muscle fibers due to the locking of actin-myosin filaments when ATP is depleted.

Shkrum MJ, Ramsay DA. Forensic pathology of trauma: common problems for the pathologist. Humana Press, 2007. [link]

• Yes
• Pacemaker interference can occur from cell phones, but they have to be within 10 cm of the pacemaker. Reported effects include inappropriate inhibition, atrial oversensing or synchronous rapid ventricular pacing from misinterpretation of the cell phone signal as atrial activity. Only about 1 in 100,000 pacemaker patients have mobile phone-related problems.
• Practical advice to give to pacemaker patients is to use mobile phones in the hand opposite the side of the implanted pacemaker, and to avoid carrying the phone in the breast pocket near the pacemaker.

Irnich W, Batz L, Müller R, Tobisch R. Electromagnetic interference of pacemakers by mobile phones. Pacing Clin Electrophysiol. 1996 Oct;19(10):1431-46. PMID: 8904533.

Myerson SG, Mitchell AR. Mobile phones in hospitals. BMJ. 2003 Mar 1;326(7387):460-1. PMID: 12609917; PMCID: PMC1125359.

• Alice Springs, in the very center of Australia.
  
• Do the math — this suggests that every person in Alice Springs has an average of 1.5 presentations to the ED every year!
• Possible reasons for this include:

• social deprivation of the local indigenous population contributes to greater prevalence and severity of a wide range of medical illnesses.
• high rates of violence, particularly related to alcohol.
• a large catchment area with presentations from out of town – Alice Springs Hospital has 189 beds servicing an area of 1.6 million square kilometres.

Click to enlarge (Source: Wikipedia)

• Coprolalia is involuntary swearing or the involuntary utterance of obscene words or socially inappropriate and derogatory remarks.
• The term comes from the Greek κόπρος (kopros) meaning “feces” and λαλιά (lalia) from lalein, “to talk”. Literally, “talk sh!t”.
• Coprolalia is most commonly attributed to Tourette Syndrome (coprolalia occurs in about 10-20% of cases) but can occur in other tic disorders, and other neurological conditions including stroke, encephalitis, seizure disorders and dementia.
• Interestingly,  there are reports of deaf patients with Tourette’s who involuntarily swear using sign language. Related phenomena include copropraxia (performing obscene or forbidden gestures) and coprographia (making obscene writings or drawings).

http://www.youtube.com/watch?v=e4xOW7i1YjA

• Look for long toenails on the contralateral foot.
• A fatal case of varicose vein injury inflicted by an excessively long toenail occurred in New Zealand and was described in the Lancet in 2003.

Fraser R. Nail in the coffin. Lancet. 2003 Jan 4;361(9351):90. PMID: 12517518. [free fulltext]

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).

• Batchvarov VN, Malik M, Camm AJ. Incorrect electrode cable connection during electrocardiographic recording. Europace. 2007 Nov;9(11):1081-90. Epub 2007 Oct 10. Review. PMID: 17932025.

This paper is a thing of beauty for the ECG nerd – all the ways incorrect lead placement can play havoc with an ECG.

Recommended by Chris Nickson
Fulltext

• Beck LH. Should the actual or the corrected serum sodium be used to calculate the anion gap in diabetic ketoacidosis? Cleve Clin J Med. 2001 Aug;68(8):673-4. PMID: 11510523.

If only I had a dollar for every time someone has asked me the question this little paper succinctly answers…

Recommended by Chris Nickson
Fulltext

• Knox J, Cowan R, Doyle J & al. Murray Valley encephalitis: a review of clinical features, diagnosis and treatment. MJ; Epub 23 Jan 2012

For Aussies, good review on Murray River encephalitis – a very scary disease.

Recommended by Ioana Vlad
Fulltext

• McBride JT. The association of acetaminophen and asthma prevalence and severity. Pediatrics. 2011 Dec;128(6):1181-5. Epub 2011 Nov 7. PMID: 22065272.

Does APAP (aka paracetamol aka acetaminophen) cause asthma? This has bugged me since the ISAAC paper of 2008… Now McBride puts it into perspective for us.  Very Persuasive.

Recommended by Colin Parker
Learn more: empem.org – ISAAC blows wheezy whistle on APAP
Fulltext

• Humphreys I, Saraiya S, Belenky W, Dworkin J. Nasal packing with strips of cured pork as treatment for uncontrollable epistaxis in a patient with Glanzmann thrombasthenia. Ann Otol Rhinol Laryngol. 2011 Nov;120(11):732-6. PMID: 22224315.

Glanzmann thrombasthenia is a rare platelet disorder that can cause bad nose bleeds. Instead, of ligation perhaps crafting a salted pork nasal tampon is the answer… These authors seem to think so. Is it the salt content, the presence of tissue factor, coincidence or something else?

Recommended by Joe Lex

• Kamp MA, Slotty P, Sarikaya-Seiwert S, Steiger HJ, Hänggi D.  Traumatic brain injuries in illustrated literature: experience from a series of over 700 head injuries in the Asterix comic books.  Acta Neurochir (Wien).  2011 Jun;153(6):1351-5; discussion 1355.  PMID: 21472486.

How far can you stick your tongue in your cheek? “A retrospective analysis of traumatic brain injury (TBI) in all 34 Asterix comic books was performed by examining the initial neurological status and signs of TBI. Seven hundred and four TBIs were identified. The majority of persons involved were adult and male. The major cause of trauma was assault (98.8%). Traumata were classified to be severe in over 50% (GCS 3-8).” And on and on and on…

Recommended by Joe Lex

• van Schalkwyk J, Davidson J, Palmer B, Hope V. Ayurvedic medicine: patients in peril from plumbism. N Z Med J. 2006 May 5;119(1233):U1958. PMID: 16680175.

Alternative medicines may be more than than simply ineffective. Think heavy metal poisoning – in these cases, lead – when you come across a patient taking Ayurvedic medicines.

Recommended by Chris Nickson

• Bhatia R, Morley H, Singh J, Offiah C, Yeh J. Craniocervical stab injury: the importance of neurovascular and ligamentous imaging. Emerg Radiol. 2012 Jan;19(1):83-5. Epub 2011 Nov 29. PMID: 22124685

Brilliant case report on what was pretty much a Brown-Sequard syndrome above C1! The CT images of the knife in the atlas are worth it alone.

Recommended by Andy Neill

Wow 2012 already- how time flies? – Which means it is time to quote Groucho Marx. “Time flies like an arrow. Fruit flies like a banana.” Didn’t like that one? How about” Marry me and I’ll never look at another horse again”. (that was Groucho too) All seriousness aside, however, this article that I am about to present was designed for testing residents but the tables are a good basis for a practice that is not common in many countries. Triage levels are important for us to organize our work. This allows us to also sort the patients out to determine who needs a higher level of care that may need an EM specialist instead of the intern seeing them. If your ED is already doing this, fine- but there are many ways how to do this and I would welcome to hear the methods you use in your ED.(AEM 18(3)E8)

Small study and it studied kids between the ages of 11 to 17 years –which is a big range in age, but the subject is very big now. Many of kids who play contact sports can get knocked out and we are often asked who can be allowed to return to the game. The best tests include verbal memory, processing speed and reaction time which when done at the time of injury most correlates with the improvement scores that will be seen two weeks down the line (AEM 18(3)256). What is the current teaching now is not to let them go back to the game so fast, so in your clinic or in the ED- do not give recommendations for when the athlete can return to sports unless you will be following up with him and can do these tests.

The classic teaching is that subsegmental pulmonary embolism is less likely to case trouble. Actually, someone has actually looked at this in Korea. They found that these were generally safe with no mortality in their study, and with much less oxygenation and hemodynamic instability issues. (Respir 80(6)500). There are problems here. Many of the patients that had subsegmental embolisms received anticoagulant therapy as treatment and perhaps that is why they did well. There were only 334 patients, and they used three types of imaging- pulmonary angio (anyone still doing that?), CT and indirect CT venography which I am not sure what that is. In any case we know that CT misses many subsegmental PEs, so we can’t really be sure about the benign nature of these PEs since we do not know who had them and went home since the CT was normal. The big question- is this a risk for a bigger PE down the line or are subsegmental PEs just a normal everyday occurrence that we all may experience and has no clinical relevance.

This is perhaps one of the worst journals I screen but it is hard to screw up when you are meta analysing a well known concern. Since however, there may be some new readers (EMU averages new ones almost every week) I will mention it. The use of acetaminophen (paracetamol) seems to increase the risk of childhood asthma. (Clin Exper All 41(4)482 ). However, there were only six studies and their quality was not evaluated. Furthermore the risk ratio is only 1.21 which is only a slightly increased risk. Since we believe that this is the most acceptable drug in pregnancy- exercise some caution.

Here is a bone for my EMS readers (I hope to dedicate a EMU roundtable to you guys- will welcome your questions). But please read the whole paragraph. They did transcranial dopplers on 18 head injured patients to help stratify the patients (Acta Anaes Scand 55(4)422) Not clear if this improved care or mortality, but in a long transit time this could help. Now this was a French study and their system is much different – they have specialized hospitals- ones for heart, ones for lungs etc, and docs often are in the ambulances, specifically anesthesiologists. However, in Israel, and some other countries physicians do ride the ambulances but they are basically unable to perform procedures that the paramedics are unable to. Furthermore they are usually poorly trained. Should we go to the USA system where physician accompaniment is rare?

Resuscitation news – They compared two self teaching shorter versions of BLS with the traditional course and found that the students did just as well if they took the self teaching course. (Resuc 82(3)319). Now these were medical students and the way they established equality of skills seemed to be asinine, but if you need to have badge courses (and I am against them for emergency physicians) this way of teaching would expose more people to this critical skill. Indeed youtube could be a great source as well (ibid 332 ) but the quality of these videos were highly variable.

Hi, ICU guys- you are probably are making fun of me for something you have known for quite a while, but statins have anti-inflammatory effects (I knew that), anti oxidant effects (can’t see why that would help), immunomodulatory effects (depends what those are) and anti-apoptotic effects (no idea what that is) and they think it will work well for septic shock. (Eur J Int Med 22(2)125 ) The evidence though in this review is kind of sketchy. They are now looking into this also for pretreatment before PTCA. (Circ 123(15)1622) This was also a meta analysis but I do not know how much was confounded by the fact that so many patients undergoing PTCA are taking statins anyhow.

Trauma guys laugh it me a lot as well, but please reconsider pan scanning – in kids at least and in everyone as well. While a standard chest film is only .05 milli Sieverts; kids in this study got on average 3 scans per patient and received 17.43 milli Sieverts. That is about 350 chest films (J Trauma 70(3)724 ). Considering that little kids get more radiation distributed over smaller surface areas, this could be devastating. They found these dosages to be in the range for increased chances for solid cancers, thyroid cancer and leukemia.

I always welcome good evidence, and looking at manipulation therapy for treatment of radiculopathy they found that there is moderate evidence it works for lumbar radiculopathy, but only if it is acute. For chronic lumbar and cervical radiculopathy there is no evidence. (Phys Med Rehab Clin No Amer 22(1)105 )

Ken I.- sit down before you read this. They polled academic physicians and found they on average see one death a month in the ED. The overwhelming majority received little or no training on how to cope with this. Debriefing occurred almost never and many reported insomnia and fatigue as well as sadness and disappointment after witnessing deaths. Common coping mechanisms included talking with colleagues and – you guessed it- continuing to work. (AEM 18(3)255 ) It seems that powerful experiences with death – like an unexpected one- teach physicians a lot on coping (Acad Med 80(7)648). I for one wish I was given more training in this- I still – after 26 years in the business do not know how to do this well. Ken I, Mike D – would you have some pointers for our readers?

An interesting perspective on ultrasound written by a residency director. Often we feel befuddled when we see our residents whizzing by with the machine and we do not even know where the on off button is. There are many relevant questions that could be asked on this technology which has truly changed EM practice. What about places that do not have access to this technology in the ED? What about studies we do but are not ready to take full responsibility for (like Doppler of the lower extremity?) And what to do when the technology is unavailable- we can put in a CVP blindly but can our residents who have never done it without ultrasound? (AEM 18(3)309 ) I think we need to embrace the technology and make sure everyone is well trained in this-even if it is by learning from radiologists or our own residents. We need to assure competency in the method as well. We can no longer stand against this and we cannot ignore it either. So be honest- how many of you are as good with the probe as you are with the ET tube? (and are over the age of 45)

You do not have a lot of time with the acute scrotum and the six hours often quoted is ischemic time on dog testicles- not overly relevant to humans. There are a lot of scrotums in China (I bet you didn’t know that- see- it is good you get EMU) and when they studied this they found that there was a lot of overlap in the signs of an acute scrotum meaning that physical exam is not reliable and ultrasound was also not reliable. They concluded that one must have a low threshold for exploration in these cases. (PEC 27(4)270).

They looked at scrotums in the UK (where by the way the have a lot less scrotums) and found that torsion was the most common finding, but only barely –that is 51%. They therefore recommend exploration for everyone with an acute scrotum but they ignore that in 49% of the cases the surgery was unnecessary (and painful I assume) (BJU Int 107(6)990). I think the solution must be that someone must invent a laparascope for the scrotum.

Two other points: Firstly both studies took over 18 and ten years respectively-but it took that long to get enough patients. The UK study by the way found that age didn’t help either to rule out torsion.

Hot Flash: (pun intended) I just spoke to one of our senior urologists who corrected my misconceptions- a scrotal exploration involves an incision of 1 cm and is a short procedure that is painless. So if in doubt get that urologist in and let him take a look.

This has got to help someone somewhere. None of these drugs really work, but there may be some family guys that swear by them so let’s go. Transplant patients can not take all OTC cough and cold preps. Diphenyhydramine has anticholinergic properties that can directly affect even a denervated heart. It also interacts with cyclosporine. Dextromethorphan is OK, except in liver transplant patients. Guaifensin is OK in transplants patients except those with kidney or lung transplants or renal impairment. Codiene is OK for all transplant patients except those with renal impairment. Now I know you all saw this article already- for sure Alex S saw it in Up to Date, but there may one person out there that does not get this journal so I brought it. ( Progress Transplant 21(1) 6 )

The talk of the town- everyone is very interested in Ian Stiell’s newest project- the rapid discharge of patients with AF who –per his protocol- get a one hour drip of procainamide and then electrical shock if it doesn’t work. Some of the positives from this article that I really like- procainamide is a good drug and I am glad that amiodarone is not the Messiah any more- it really doesn’t work that well. Furthermore, he advances that rate control is not necessary and in an interview he said that it may even make conversion harder- though I have no evidence for this supposition. (CJEM 12(3)181 ).

Now the bad part. I spoke with Dr. Odaya who reviewed this article for a presentation in our journal club, and I would like to present her comments verbatim.

“The study was a cohort study with no placebo group, which is not a bad thing in this case, but a comparison group with electrical cardioverison alone or versus amiodarone for example would have been nice. Many of these patients presented more than once, so actually more patients presented more than once than those who presented only once. So it could be that the patients that it helped re presented and if there sample size was greater they would have found more who did not respond. Looking carefully on the charts in the study, 120 patients received anti arrythmics before coming (including 8 who were taking procainamide already) and great amounts were taking rate controlling meds- which could have influenced the results.)”

Other questions I asked: the charts in the article showed that patients received 25 -2000 mg of procainamide despite the protocol being for 1 gm- could it be on the low side these patients converted spontaneously? And why were A flutter patients in the ED for an average of 6 hours? I heard Ian speak in an interview on EM RAP and he admitted that electrical conversion is also just fine, and I find it helps us discharge our patients must faster. Ian did admit no American journal would accept this article- which I find odd. By the way, not to dis Dr. Stiell but Dr. Odaya is our intern. Bright kid, no?

This article describes on going research which will interest me only when the article is finally published, but the statistics were important. Intracranial aneurysms occur in 0.4-0.6% of the general population; the total risk of rupture may be about 2% for all aneurysms, but indeed if they are less than 7 mm in diameter, the risk is only 0.1%. This is important for us to know because often we do CT’s for headaches, and find aneurysms that are not leaking-and it appears we do not need to do much for them. Surgical treatment for aneurysms cares a 1 in six morbidity rate and a mortality rate of 2.6% to 15.7% – probably a wide range due to location of the aneurysms. Coiling is much safer but has an incomplete occlusion rate in 40% and aneurysms recur in 34%. Risks for rupture include: diameter greater than 7 mm, posterior circulation location, small parent artery, smoking, and hypertension. (Can J Neuro Sci 38:191 )

Cardiologists can be cantankerous group and they do not often agree with each other (or as Jay Leno says- 9 out of ten doctors agree the other one is an idiot). And indeed the Canadians, the Americans and the Europeans all came out with their own guidelines for the treatment of Atrial fibrillation. All of these guidelines agreed to more lenient rate control (if you want this)-now 110 beats per minute are acceptable, but the Europeans and the Americans agree to this only with provisos whereas the Canadians are OK with this throughout. Rhythm control- the Canadians are the only ones that do not restrict the use of Sotalol and class IC(propafenone , flecanide, ibutilide) from those who have LVH. The Canadians also do not believe that the use of dronedarone is reasonable on the basis that it saves admissions for AF, although they agree that it can be used. The Americans strongly recommend the use of ablation for a fib that fails anti arrhythmic therapy. The Canadians are the only ones recommending dabigatran to prevent strokes as being superior to warfarin, but if you read EMU, you know that this is not true. In any case, it seems from the article that the Canadian approach is the most enlightened but I would have expected that being that this article is from the Can J of Cardio 27(1)7 .

While we are speaking about subjects close to my heart, EM RAP recently asked Amal Mattu if troponin elevation is pathologic in SVT. Dr. Mattu said no, but presented no evidence for this. Well there is an article that shows that is of no significance see ibid 105 . Alas, wouldn’t it be great if it was good evidence, but there were only 73 patients of whom only 24 had an increase in troponin and 19 of them underwent stress tests of which 2 were positive and one needed intervention- if you can trust stress tests which you can’t. But I still do not measure troponin in SVT and think you shouldn’t either. All though I do sometimes wonder why all the SVT patients I send home die. (only kidding- really)

Just what exactly are you bringing home with you? If you live in the UK you are probably undergoing mandatory screening to see if they can detect your pet MRSA. And as can be expected there is no or little literature with regards to whether routine screening is useful, what the prevalence of MRSA among health care workers is, how it is transmitted and what to do with the results of this screening. (J Hospital Inf 77(4)285 ). However this bug in the community so we could expand the screening to the clinics too. If we knew it made a difference- which we do not know.

I am certainly not a genius in this subject and other than Didi B don’t know anyone who is, but if you took your boards you learned that the oximes – use with atropine of course- are the treatment for organophosphate poisoning. If you are uncertain as to what this medication is – in the USA it is Pralidoxime (2 PAM) and in Israel Toxiganon. Cochrane as usual says there is no proof it works (or that it doesn’t damage) but add that the organophosphate re-adheres to the receptor after the oxime is done working in massive overdoes and doesn’t work when dimethyl organophosphate presents in a late fashion. (Cochrane 5085:2011 ) Does this help anyone? Well, maybe. If your poisoned patient doesn’t get better, so up the atropine and perhaps the Pralidoxime as well- if it is safe to do so- we don’t know this either.

I have mentioned this before, but what can I say- it takes time for internists to clean their ears out. Also you FPs may see patients taking these drugs if they are pre dialysis patients. Sodium Polystyrene Sulfonate- also known as Kexylate in most of the world is used to lower potassium in the blood. It can given by mouth or by enema. It takes time to work so other therapies (calcium, 
Ventolin inhalations, insulin and glucose, loop diuretics) are often given first. This article says Kaexylate may take a very long time to work; in fact it may not work at all. Indeed this medication was introduced in 1958 when safety and effectiveness did not have to be proven. There have actually been no studies that have proven it works. Can it hurt? Well when given with sorbitol it causes colonic necrosis. ( J Am Soc Neprhol 21(5)733 ). We do have other options after the acute care including dialysis and loop diuretics but I think many of us would believe from our experience that it does work- which leaves us with- when does it and when does it not? Only your hairdresser may know for sure.

Synthetic cannaboids are out there- they are legal in many countries, and they are available over the internet. They like bath salts are legal because they are labeled not for human consumption, but when smoked or ingested give a high. Toxicity data are limited. There are some case reports that this is not innocuous. One report after ingestion is seizures and SVT (Clin Tox 49(8)760). Hallucinations, hypertension and chest pain also occur but all resolve within 2 -4 hours. Are there long term effects? I know some folks in Oregon that would probably say no (Ann Pharm 4593)414)

NSAIDS bashing again. (Maybe it is time I got a life, no?) The safest NSAID in cardiac disease remains naproxen- which we have mentioned in the past .However, there is still an increase of 30% MIs in those taking these naproxen- meaning other NSAIDS are even worse (Nature Rev Card 8(4)193 ). So you will say to me- Hey, you can’t outsmart me, I read EMU-I will recommend they take aspirin for pain- which is fine if you are in the USA, but in many countries- Israel included – you can’t get higher dose aspirin, only the 100 mg and you will get strange looks when you recommend that patients take 5 – 10 pills at a shot.

OK, so you are not an EP and you do not give propofol in general, but read on, because you may be in for a surprise. Propofol can sting when given IV about 60% of the time. Giving lidocaine IV or ketamine with it will reduce the pain. However the most efficacious way of preventing pain is by giving it in an antecubital vein as opposed to a hand vein. (BMJ Mar 2011 ) I always believed this anyway- where there is more muscle mass- it will hurt less. Need to take arterial blood gas? (Not sure why you would, but no matter)? Femoral probably hurts less than radial.

While we are on the subject of sedation- we have two letters from last month as replies to the use of ketamine. Lisa Amir from Schneider pediatric megapolis says:

After the update on ketamine use in Annals from Jan 2011 - we’ve gone exclusively to using ketamine without midazolam in kids.  1.5-2 mg/kg (little ones sometimes need more).  Not only do we virtually never see emergence reactions, the duration of action for ketamine without midozolam is about 10 minutes.  For most of our procedures this is long enough and we have the kids out the door about 60 minutes after completing the sedation.  If the procedure is longer (suturing, e.g. ) we just give additional boluses of ketamine 0.5 mg/kg

Pinny Halpern from Tal Aviv’s Ichalov Hospital writes:

In our department we have using a midazolam-ketamine combination for many years, with thousands of satisfied patients and many very satisfied EPs and orthopods. In fact, this is the sole sedation method allowed orthopods. It is successful approx 95% of the time, so much so that I really don’t find the need for propofol (which I love – as a former anesthetist). Emergence phenomena are so rare I can’t think of the last time I saw one. Etomidate (+/- fentanyl) is my fall back drug when needed.

I think the etomidate idea is an interesting one- what advantage does it have over propofol? (it doesn’t hit the blood pressure as hard but these are usually young patients that can handle that). I have never seen an emergence reaction either. My problems with ketamine and midazolam are that I rarely get these patients out the door that fast. Thanks for your comments.

BETS- the EBM series from the EMJ – these folks asked: kids that can fully extend their elbow- does that rule significant injury? They claim that it doesn’t but the studies are few and not of great quality, and besides, I would ask- what is considered a significant injury? (EMJ 28(4)334 ).

Even more interesting is their BET number four where they ask how useful bowel sounds are. They claim they have a high specificity for obstruction but low sensitivity meaning hearing normal bowel sounds does not rule out obstruction. (EMJ 28(4)336) This conclusion is based on only one good paper, and in addition, there are many other signs of obstruction that make checking bowel signs less relevant. I personally never check for them, and I think this article brings into question the whole concept of what in the physical exam is really helpful. I am not trashing everything we do, but we do need to question – a little. Isn’t that why you read EMU? (Or is it because you can’t find a Reader’s Digest in the smallest room of the house?)

• Kumar RD, Hirsch NP. Clinical evaluation of stethoscope-guided inflation of tracheal tube cuffs. Anaesthesia. 2011 Nov;66(11):1012-6. doi: 10.1111/j.1365-2044.2011.06853.x. Epub 2011 Aug 18. PMID: 21851343.

A cool, practical study although patient numbers are small.

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