Monday, May 16, 2011

Erythropoietin is of No Benefit in STEMI

I have to say, the outcomes of this study both surprised and did not surprise me.  A couple years ago, I read a few articles regarding erythropoietin administration in animal models of myocardial ischemia, and they actually tended towards cardioprotective effects.  However, there have been some other retrospective reviews looking at erythropoietin levels in humans that have not been quite as conclusive.

The efficacy cohort rather favored the intervention group - the most important significant difference was primary vs. rescue PCI, and significantly more EPO group patients received primary PCI.  But, then, their results section is mostly a long list of non-significant differences, and some secondary outcomes favoring placebo.  Adverse events also favored placebo.  So, I don't think we'll be seeing EPO on the code STEMI order sheet anytime soon.

As another aside, and sort of a follow-up to the Annals of Internal Medicine article a month ago regarding conflicts of interest in the new ACC Guidelines - the disclosure list for this article is massive.  It is clearly the standard of care in Cardiology to be on the payroll of multiple pharmaceutical companies in one fashion or another.

http://www.ncbi.nlm.nih.gov/pubmed/21558517

Sunday, May 15, 2011

Advanced Life Support - Not Dead Yet?

Meta-analysis of published trials, 9 for trauma and 9 for non-trauma met their inclusion criteria after review, examining OR for survival when comparing ALS to BLS.

Trauma, unsurprisingly, derives no benefit from ALS in cardiac arrest.  They even found a pooled OR of 0.89 for survival with ALS, but the CI just barely crosses 1.

But, contrary to the two most recently published prospective trials, their meta-analysis of non-trauma arrest still shows a survival benefit for ALS.  They do include a few trials from before AEDs were available in BLS in 1995, but it still doesn't explain the entire benefit.  They also cite a few studies in which a physician is part of the paramedic team, which may mean there's more to ALS than AHA ACLS, so that might be a bit of a confounder.  Hard to know what to make of this data, considering the lack of demonstrable benefit from ACLS medications and the decreased survival of patients intubated in the field in out-of-hospital arrest.

My take is still that cardiac arrest, for the moment, is still a place where significant out-of-hospital resource investment is low yield, and CPR and AED is all they need en route to the ED.

Saturday, May 14, 2011

Computerized Resuscitation in Severe Burns

This is a critical care study that showcases an interesting tool developed for ICU resuscitation of severe burns.  The authors make the case that adequate resuscitation for burns, i.e., the Parkland Formula, is necessary - but that patients are frequently over-resuscitated.  Rather than simply settling for the rigid, formulaic crystalloid infusion over the first 24 hours, they developed a computer feedback loop that altered the infusion rates based on urine output.  Think of it as insulin drip protocol or heparin infusion protocol - but instead of glucose or PTT, you're measuring UOP and adjusting the fluid rate dynamically on an hourly basis.

I like this study because they have a primary outcome - improved adherence to their UOP target - and then secondary outcome variables that matter, mortality, ICU days, ventilator-free days.  While secondary outcomes are hypothesis-generating tools, making a rational leap to connect the association between their UOP adherence and the massive improvement in mortality demonstrated would not be reproachable.

It is not a large study - and the control group had the same % BSA burn, but had significantly more % full thickness burns.  The magnitude of the mortality outcome could certainly be affected by more demographics than they report, so a follow-up is necessary.  However, the premise of a feedback loop offloading cognitive tasks from providers as part of the management of a complex system is almost certainly something we're going to see more of in medicine.

http://www.ncbi.nlm.nih.gov/pubmed/21532472

Friday, May 13, 2011

Augmentin Is Non-Inferior to Appendectomy

A lovely study out of The Lancet that tells us what we already know…is not as right as we thought it was.  We've all seen the pediatric patient, usually female, that went to their pediatrician's office with abdominal pain, had evidence of cystitis on a UA, and was prescribed amoxicillin or cephalexin.  They got a little better, but they're still having some nausea, some pain, and some loose stools.  In your ED, the ultrasound is positive for free-fluid without visualization of the appendix, and a CT scan subsequently shows evidence for appendiceal rupture.  But – as we'll see here – most cases probably resolved before you saw them.

This is a prospective study randomizing patients to antibiotics versus early surgery, and the antibiotic group here actually had a lot more success than we imagine – since all we see/remember are those patients where we discovered the "latent" appendicitis, partially treated and festering after that initial course of antibiotics.  Only 12% of their CT-proven uncomplicated appendicitis went on to have a appendectomy in the first 30 days, and 30% within a year.  So, you could almost argue that with an 88% short-term cure rate with antibiotics and a 70% medium-term cure rate, antibiotics should be first-line therapy with observation for clinical worsening.

Definitive therapy has its advantages – you could almost equate the appendix to the gallbladder, and say that the 30% recurrence is almost certain to rise in subsequent years.  But, is there an advantage to waiting to do an appendectomy on an elective basis?  Are the adhesions that might develop more or less of an issue that the risks associated with emergent surgery?  And, of course, in the female pelvis, any undertreated appendicitis represents a significant fertility risk.  This study raises great questions about whether we should change our practice regarding our approach to appendicitis, and it might just be we find a role for being less aggressive with surgery.

“Amoxicillin plus clavulanic acid versus appendicectomy for treatment of acute uncomplicated appendicitis: an open-label, non-inferiority, randomised controlled trial.”
http://www.ncbi.nlm.nih.gov/pubmed/21550483

Thursday, May 12, 2011

2010 ACLS Guidelines

I'm sure you've seen summary articles from various sources regarding updates to the ACLS algorithm for 2010.  The change in the BLS component from an A-B-C to a C-A-B with a focus on providing high-quality compression-only CPR is well-publicized.

On EM:RAP - an educational resource I simply cannot recommend highly enough as a way to mix entertainment with CME - Mel Herbert issued the challenge to submit proof of the "epinephrine-free code".  They made this hypothetical challenge based on a close reading of the new ACLS guidelines for PEA/asystole - which, if you look closely, reflect a tacit acknowledgement of the futility of ACLS medications.  Between atropine, bicarbonate, epinephrine, and calcium - various pieces of the kitchen sink available in the code cart - only epinephrine still has a role in the guidelines, but the level of evidence has decayed to IIb, which is at the "expert opinion or consensus" level.

There are a couple large studies with limitations from Scandinavia that show associations of epinephrine with poorer outcomes, or no improvement in survival with ACLS medication administration pre-hospital.  And, if you consider the vasoactive properties of epinephrine - sure it increases CPP, but its effects on the oxygen-debt of the peripheral vascular bed, the effect on subendocardial perfusion and infarct size - imagine giving epinephrine to a STEMI patient.  We're injuring the most important organ system of interest in cardiac arrest.  I am more than willing to take up the challenge of epinephrine-free resuscitation - I just need to find some evidence to support something else to give in the meantime so I'm not reported to the Chief of Staff so it looks like I'm trying.  Anyone have anything in mind?

http://circ.ahajournals.org/content/vol122/18_suppl_3/
http://www.ncbi.nlm.nih.gov/pubmed/12104107
http://www.ncbi.nlm.nih.gov/pubmed/19934423

Wednesday, May 11, 2011

Comparison of Adult Head CT Rules in Pediatrics

Interesting - if limited in prospective use - retrospective comparison of the New Orleans, Canadian, and NEXUS II instruments for risk stratifying adults suffering minor head trauma.  Busy, urban children's ED went through 8 years of data to find over 6000 patients with minor head trauma.

Unfortunately, they only looked at the 2,101 that received a head CT, so we lose a huge chunk of our population to "clinical judgement" that could have profoundly affected the specificity of the rules and perhaps had small effects on their sensitivity.

Full of interesting tidbits - 25% of their study population was under 2 years old, but 41% of their injuries were detected in the under 2 population.  Sensitivity and specificity essentially rose and fell with the percentage of the cohort scanned - the New Orleans rule would have scanned 89% of their cohort...that had an incidence of 4.4% of intracranial injury.  That made the sensitivity 96%, but the specificity 11% - and I hate to think what the specificity would have been if the other 4000 patients had been included.  The Canadian Rule scanned the least, missed the most at 65% sensitivity, but achieved a 36% specificity.

But the real question is - what's the point?  The PECARN criteria get you up to ~96% sensitivity with a specificity of 53-58%.  Kids aren't small adults - especially infants, and especially in trauma.  Don't apply adult criteria in kids.

http://www.ncbi.nlm.nih.gov/pubmed/21465153

Tuesday, May 10, 2011

"Suspended Animation"

This is, actually, an important avenue of contemporary research, highly funded by DARPA at Texas A&M - although this research is from Germany - and this article is about one of the methods tested that got into the lay press a year two back.

The driving principle is that, the best way to keep someone newly dead from starting to go down all those cellular pathways that make cells go "pop", is to shut down cellular metabolism and starve those pathways of cellular energy.  This seems like a sound idea - although, a lot of other cellular pathways that maintain cellular integrity and electrochemical gradient stability are also funded by those same pathways.  But, the theory is that if you have a tissue hypoxic event, slow everything down to buy you more time, fix the overriding problem, and then resuscitate the patient.

Didn't work for these folks.  61 Wistar rats given hydrogen sulfide as their agent to paralyze cellular metabolism.  Significantly better pH and less base excess initially during acute resuscitation from cellular hypoxia, so it is doing something to prevent tissue oxygen debt - but their primary outcome of neurologic preservation, they showed temporary neurologic preservation at an interim test, but no differences at the 7 day point, and no histochemical differences after sacrifice.

This sort of research is still clearly poking about in the dark right now, but it is absolutely the future of resuscitation - to give us a reason for hope in the trauma bay that return of circulation is neurologically intact and not simply just for organ donation.

http://dx.doi.org/10.1016/j.resuscitation.2011.03.038

Monday, May 9, 2011

Vital Sign "Triggers"

So, this was an interesting article about a system of vital sign "triggers" an ED implemented to get nurses to flag specific patients for more urgent attention.  Not unexpectedly, the study finds that, when nurses get physician's attention, everything happens more rapidly to those patients, orders, antibiotics, and disposition.  The problem is, the article doesn't address the appropriateness or any unintended consequences of this sort of intervention.  The theory would be that these abnormal vital signs represent patients that need more urgent evaluation, but vital signs are always just one piece of the puzzle.  In any event, this study spotlights something that can be reasonably construed as important - nurses should be educated to recognize potentially ill patients and notify physicians.

Of course, in the back of my mind, I was envisioning our ED (and likely many around it) which rooms patients first, and then triages them - and it then becomes the responsibility of the nurse whose zone they have entered to take and record vital signs.  This results in patients being roomed much faster - which many studies have shown is likely a good thing.  Unfortunately, when a patient is roomed to the high-acuity side based on chief complaint, the nurse to which they are assigned may be quite busy with their other high-acuity patients...and that patient may just sit in the room for some time without an assessment or vital signs.

Everything has potential unintended consequences.

http://www.ncbi.nlm.nih.gov/pubmed/21521399

Sunday, May 8, 2011

...and Here is Why the Elderly Are Falling

Orthostatic intolerance.

Not much more to say.

An entire quarter of their convenience sample of elderly (mostly female) volunteers had a 60 point drop in their blood pressure upon standing, with only a modicum of recovery within 2 minutes.

Antihypertensive polypharmacy was weakly associated with orthostatic intolerance, and the presence of orthostatic intolerance was weakly associated with an increased number of falls.

So, if the disease (hypertension) doesn't harm you, the treatment will.

http://www.ncbi.nlm.nih.gov/pubmed/21438868

Saturday, May 7, 2011

2005 AHA CPR Guideline Changes Had No Effect

Most recently, the new "hands-only" CPR guidelines have received a lot of press and attention, and there's a lot of excellent research showing that any intervention that stops CPR decreases survival.  Well, the last time they revised the CPR guidelines, they were also intended to decrease CPR pauses, including changing the manner in which defibrillation was performed, making longer CPR intervals, and eliminating pulse checks after shocks.

The "Resuscitations Outcomes Consortium" did a crossover study looking at survival to hospital discharge before and after the implementation of the new guidelines...and they found no statistically significant differences.  They did find a clinically significant improvement in VT/VF survival that went from 14% to 18%, but the p-value was 0.06 - and it's hard to attribute that solely to the guidelines because there are other significant baseline differences, particularly a 28% to 34% increase in bystander CPR.

Should be interesting to see if widespread implementation of the new CPR guidelines increase overall or subgroup survival.

The paper also mentions their current studies, looking at whether automated devices improve outcomes and when AED analysis should be performed in sequence.

http://www.ncbi.nlm.nih.gov/pubmed/21497983

Thursday, May 5, 2011

Early Recognition of Massive Transfusion

From trauma resuscitation, a Chinese study trying to predict who will need massive transfusion after trauma.  They have a 7-item scoring system retrospectively derived...and it's probably not terribly helpful.

It's a nice idea, considering there's only so much blood readily available in the bank, and a lot of massive transfusion protocols are 1:1 with FFP and sometimes platelets, so advance warning based on the initial clinical evaluation would definitely be helpful.  There are some interesting pieces of information in the paper, although, I wish they had all their OR listed for massive transfusion, as opposed to just the ones that shook out from their stepwise regression.  Their highest predictor for massive transfusion - a hemoglobin < 7 g/dL with an OR 45.7.  SBP < 90 and positive CT or FAST were also predictors with useful OR.  Their rule is a little unusual for a theoretically beneficial intervention (massive transfusion), as they focus on specificity rather than sensitivity - probably due to a need to conserve blood component products.

In the end, though, I think most folks with a hypotensive trauma patient whose FAST is positive and a Hgb < 7 could clinically predict massive transfusion as well as this rule does.

http://www.ncbi.nlm.nih.gov/pubmed/21458905

Wednesday, May 4, 2011

Pediatric Sedation with Propofol

Lovely descriptive statistics of 25,000 occurrences of propofol sedation in children.

Interestingly - 75% of their sedations occurred in radiology.  My experience has primarily been to sedate children for uncomfortable procedures - but I am aware that our pediatric critical care intensivists staff the MRI machine specifically to run sedations for children for imaging.

2.3% had "serious adverse events" - although their "other adverse events" includes 1.3% who had "unexpected need for PPV", which, to me, seems rather serious.  1% had airway obstruction, another 1% had desaturation and 0.5% had apnea.  They also did some chart mining to see if anything showed up as associated with a serious adverse event.  The highest OR was only 4.6, and that was when an "upper respiratory" diagnosis was documented in the chart.  Other associations included prematurity, and then the addition of benzo, ketamine, anticholinergics, or opioids to the sedation.

I would say there are a couple emerging trends that might help further increase sedation safety - addition of end-tidal CO2 monitoring might give better warning of apnea and desaturation, and increased use of nitrous oxide may reduce the number of propofol sedations needed.  Otherwise - be ready for too much excitement in one out of fifty pediatric sedations.

http://www.ncbi.nlm.nih.gov/pubmed/21513827

Tuesday, May 3, 2011

MRSA is Everywhere and You Can't Stop It

No doubt your hospital has an infection control committee, signs for handwashing, sterile showers, plasma arc denudes, etc. and your e-mail box is filled with Journey to Zero or Destination: Excellence spam.

Unfortunately, it didn't seem to work up at Mayo.  They had ICUs where they put signs up trying to inspire more barrier precautions and hand hygiene, they did more surveillance and topical intranasal antibiotics - and the intervention group valiantly tried to obey.  They were somewhat poor in their compliance with suggested barrier precautions, but they were used far more often than in the control clusters - and they found no differences in any of their measures of MRSA or VRE colonization or infection following their intervention.

I will certainly not argue against cleanliness and godliness, but I am impressed they published this lovely negative study to confound us and make us think about how we should go about focusing our resources effectively.

http://www.ncbi.nlm.nih.gov/pubmed/21488763

Monday, May 2, 2011

News Flash: Dilaudid Treats Pain

Albert Einstein in Montefiore is singlehandedly, repeatedly pushing literature regarding appropriate titration of pain control in the Emergency Department.  They have several previously published papers describing their hydromorphone 1 + 1 protocol, describing its safety and efficacy.  This paper is their prospective, randomized version demonstrating its safety and superiority to "usual practice".  You could implement their protocol tomorrow and have better narcotic pain control in your ED.  It clearly works.

But the real issue this line of research uncovers is not that they've discovered a magic protocol.  What we're missing by taking the simple interpretation is more that our pain control in the ED is flawed.  If you look at the morphine equivalents their patients received in this article, they're preposterous.  I am a huge proponent of 0.1mg/kg for morphine - even in adults - and their mean dose in the "usual care" arm was 6mg morphine equivalents, and their mean additional dose was 3mg.  0.1mg/kg is a starting dose for morphine that gives less than 50% of patients adequate pain relief - which is where the second part of their protocol comes in.  Scheduled reassessment for pain and a standing order for additional medication is another area where "usual care" will obviously fall behind, simply because of the uncontrollable chaos of the ED.

So, my take home from this article is that protocolized, standing orders for narcotic analgesia in appropriately selected patients is safe and effective, and, you can use their protocol or develop your own.

http://www.ncbi.nlm.nih.gov/pubmed/21507527

Sunday, May 1, 2011

Ardbeg Supernova

Sunday Scotchday.

This is a rather special scotch I bought a friend as a gift.  It comes from an Islay distillery with a reputation for strong notes of peat, and this bottling is "the peatiest", hence, the special Supernova designation.  They've even gone so far as to scientifically prove the peatiness by measuring a phenol level.

What's surprising about this Scotch is how smooth it is.  Obviously, at 60% alcohol by volume, it's a harsh beverage until you dilute out the paint thinner quality - but once you do that, you it is truly a unique drinking experience in how it truly builds and explodes on your palate in a very pleasant, prolonged finish. Good luck finding this in a local store - I had to order it off the internet from a distributor who did ship to the U.S.

http://www.ardbeg.com//ardbeg/whisky/ardbeg-supernova

Saturday, April 30, 2011

Badgering Your Consultants to Death

This article describes a fascinating and absolutely untenable situation with numbers that just defy comprehension.

At an academic teaching hospital in Korea, 75% required consultation towards their admission rate of 36% - and their ED LOS median was seven hours.  Then, they implemented this brutal system in which an automated computer protocol paged out a consultation - and then, at the three hour mark - if there was still no disposition, they autopaged every resident in the consulted department.  Then, at the six hour mark, a page went out to every resident and faculty member in the consulted department regarding the disposition delay.  And their median ED LOS and time to disposition basically each improved by an hour and a half with this intervention.

So, this situation is insane.  Their admission rate is pretty high, but I still cannot fathom consulting on 75% of my patients.  And, these time to disposition numbers are equally alien, especially to a community emergency physician.  At my hospital, if a consultation goes over one hour in our EDIS, the badgering begins - but it's more likely friendly, desperate begging as opposed to this hospital's automated irritant spam.

So, shed a tear for Korea and their dysfunctional ED.

http://www.ncbi.nlm.nih.gov/pubmed/21496143

Friday, April 29, 2011

Intracranial Extension of Sinusitis in Children

Interesting descriptive study of a decade's worth of children transferred/admitted to Texas Children's in Houston with intra-orbital or intra-cranial extension of their sinusitis.  It's really just a summary of the clinical and hospital courses of 118 patients identified through retrospective chart review.

Interesting tidbits:
- Of these patients, 40% had been prescribed outpatient courses of antibiotics prior to the time of diagnosis of intra-cranial or intra-orbital extension.
- All patients with intra-orbital involvement presented with eye swelling.
- Intra-cranial extension had substantially (and significantly) more headache and vomiting, and only 67% received antibiotics prior to transfer.
- Identical numbers in each group - 16% - of patients were afebrile upon presentation.
- 33% of patients with intracranial extension of sinusitis did not complain of a URI-like syndrome at presentation.
- Frontal sinus involvement was associated with 84% of their intra-cranial extension.
- All organisms recovered were sensitive to clindamycin or vancomycin plus cefotaxime except for a single pseudomonal infection.
- There were no deaths, and four patients had persistent neurologic or visual sequelae.

Short summary - orbital cellulitis was a little more straightforward in diagnosis than intracranial extension of sinusitis, and a significant minority of both groups would definitely diagnostic challenges.  CT imaging, anathema as it may be, is the diagnostic modality of choice.

http://www.ncbi.nlm.nih.gov/pubmed/20970813

Thursday, April 28, 2011

Psychiatry & ED Agreement

Not as helpful an article as I hoped when I pulled it to peruse.  Part of the issue is the surveys are administered to psychiatry and emergency department residents regarding their evaluation of the patient, so you're almost certain to have a lot more variability - not just in assessment, but in level of understanding of language and the process of acute psychiatric assessment.

Where I'm not surprised we have a low kappa with our psych colleagues are areas like mood disorders - as emergency physicians are looking more at threat to themselves, threat to others, acute psychosis, and other factors affecting their global level of function to determine whether they are safe for discharge.  What's interesting are the 2x2 tables regarding things like suicidality, where psychiatry is eliciting suicidality in a significant number of individuals where that was not reported by the emergency physician.  Out in community practice where psychiatry is not always readily available, the discharge of psychiatry patients is a high-risk endeavor - and I would have expected the emergency physician to be more attuned to suicide risk and document a lot more concern for suicidality that was deemed not an issue for the consulting team.

Mostly just an article to read out of passing curiosity that won't impact your practice.

Wednesday, April 27, 2011

More Conflicts of Interest

I don't know if I'm the only one who gets depressed by these sorts of articles.  You have the progression through medical school and residency, you finally start feeling up-to-date on current treatment, your Grand Rounds invited speakers present results from some trials, and you think you're fully armed to provide the best care modern medicine can provide.

And, then you discover that it's all a stack of cards predicated on results influenced by pharmaceutical funding.

This article is from JAMA, again, very important topic given studies performed with pharmaceutical funding have a fourfold greater chance of reporting positive results.  They looked at meta-analysis, one of the techniques we try to use to increase statistical power in our reading of the literature.  They discovered that nearly no meta-analyses included comment on whether the included studies were funded by pharmaceutical literature - even though 60% of the studies reported funding sources, and 70% of those studies reported receiving funding from the pharmaceutical industry - and the same sort of dismal reporting for author conflicts of interest.  What it means - it's another cautionary tale regarding how pervasive the masking of conflicts of interest really is, and how easily it creeps into the medical literature without our knowledge.

http://www.ncbi.nlm.nih.gov/pubmed/21386079

Tuesday, April 26, 2011

Adrenal Insufficiency in Pediatric Shock

This falls into the "don't use etomidate" pile of literature.  Well-demonstrated, primarily in the pediatric literature, that etomidate and its association with adrenal insufficiency results in poorer outcomes in shock.  This article doesn't look at etomidate, but rather it describes relative or absolute adrenal insufficiency in pediatric shock, and finds it relatively pervasive.  It then finds an association between their two definitions of adrenal insufficiency and length of stay, length of ventilator days, and required doses of vasopressors.  They only 5% mortality in their study, so they can't comment on any mortality association.

So, this is another study that helps describe why etomidate may be contributing to poorer outcomes.  The days of ketamine + rocuronium RSI are coming (we'll save the succinylcholine vs rocuronium debate for another day).

http://www.ncbi.nlm.nih.gov/pubmed/21336126

Monday, April 25, 2011

Out of Hospital Arrest Score Validation

There are nice studies in the U.S. defining and validating a rule that determines which patients are unlikely to have ROSC or survival to hospital discharge, e.g. BLS-TOR.  This is a study from France that looks at people who do have ROSC to see, not just if they'll survive, but survival where the patient is not severely disabled or vegetative.  One of the nice things about Europe is that their cultural perception of "life" really has to do more with living, and not just simply "being alive".  So, whether we can actually implement something like this in the U.S. may be difficult.

It's a chart review, which limits its quality to some extent.  The other real issue I have with this OHCA score is its complexity - it incorporates initial rhythm, no-flow and low-flow intervals, and admission levels of creatinine and lactate.  The U.S. validation cohort had 34% therapeutic hypothermia, which is pretty good - the derivation cohort was only at 11%.  Predictors of good neurologic outcome, consistent with other articles: ventricular fibrillation, bystander CPR, lower creatinine and lactate.

Unfortunately, for this rule to get up to 100% specificity, the sensitivity drops to 19%.  Alternatively, you could say that's 20% of out-of-hospital arrest ROSC that shouldn't have further intervention, which would be an important cost and medical resource utilization savings.

So, this is something that your colleagues in critical care are going to use to discuss prognosis, although I'd like to see something along these lines that helps attenuate the number of people we resuscitate until our post-resuscitation care demonstrates much, much improved outcomes.

http://www.ncbi.nlm.nih.gov/pubmed/21494106

Sunday, April 24, 2011

"Teachable Moments"

From the critical care literature, looking at whether the ICU admission represents a "teachable moment" for counseling against health-endangering behaviors.  It's a review article asking the question whether interventions at the time of admission to an ICU - i.e., a close brush with death - are effective.

This is relevant to the Emergency Department for those situations where you want to shake your patients and tell them "you did this to yourself, you fool!"

They look at the literature for nicotine cessation and for alcohol cessation.  The nicotine cessation literature is rather bleak.  They break down the interventions to <15 minutes vs. >15 minutes, and then whether contact after hospital discharge is helpful.  Pretty much, unless you have a mechanism for prolonged after-discharge contact and counseling, you won't get any meaningful results.

As far as alcohol goes - there are good studies that support questionnaires, lab work, or scoring systems to identify individuals at risk for alcohol-related injuries or illness.  However, all the studies in their review show regardless of behavioral intervention, no decrease in alcohol consumption at discharge is seen.

So, sadly, almost assuredly, the ED, with the minimal time and follow-up available to us, is unlikely to be a place where impactful counseling is feasible.

http://www.ncbi.nlm.nih.gov/pubmed/21494113

Saturday, April 23, 2011

Ultrasound Guided Subclavian Access

Ultrasound guidance and visualization of anatomy and/or the needle tip during jugular venous cannulation is, essentially, the standard of care given the frequency of complications using anatomic landmarks alone - not to mention the "growing" U.S. population that has outgrown their landmarks.  It's also the standard of care because residents finishing their training right now have never done an IJ without the ultrasound.

So, what do we do when we don't have ultrasound?  Then you're left with the decision to do subclavian or femoral.

Well, ultrasound-guided subclavians are well-described in the literature, and this is an article from our critical care colleagues with 400 subclavian access attempts - half with landmarks and half with ultrasound. Fewer complications, fewer attempts, less time to access.  Hard to argue with that.  If you aren't getting familiar with ultrasound, I would start thinking about ways to become more comfortable.

Friday, April 22, 2011

Fluoroquinolone-Resistant E. Coli

Doom and gloom from the Netherlands regarding antibiotic resistance in E. coli.  Although they focus on the resistance rates to fluoroquinolones, the more interesting take-home point from this article is the risk factors described for polypharmacy resistance.

Depending on your local resistance patterns, 88% susceptibility to E. coli for fluoroquinolones either sounds great or it sounds terrible.  What's interesting is that the strains of E. coli in this study that had fluoroquinolone resistance also had 33% resistance to amoxicillin-clavulanate, 65% resistance to TMP-SMX, and 14% had an ESBL gene.  So, you can really extend their findings to more a listing of predictive factors for resistance to multiple antibiotics.  In there study, the main univariate risk factors were indwelling catheter (OR 6.0) and prior fluoroquinolone use within six months (OR 18.6).  Less prominent, but still statistically significant were underlying urinary tract disorder (OR 2.3), recurrent UTI (OR 2.2), or recent hospitalization (OR 2.3).

Their conclusion that the presence of any of these risk factors should result in a urine culture being sent, which is reasonable - although even in the absence of risk factors, there was still an 8.2% chance of fluoroquinolone resistance.

Thursday, April 21, 2011

Norepinephrine is Superior to Dopamine

Last day of Journal Club for April.

It is very interesting how generational medical practice is - currently training physicians are accustomed to using norepinephrine for virtually everything as the vasopressor of choice (except, well, when there's a medication shortage like this past month), while previous generations have a comfort zone with dopamine.

This is a very nice study in a lot of ways and it does a good job if illustrating that dopamine and norepinephrine have very small but relevant clinical effects.  Some of their inclusion criteria are a little odd - hypoperfusion/decreased CVP after only 1000mL of crystalloid or 500mL of colloid?  And 246 of their patients suffered from hypovolemia due to acute hemorrhage - so you can really question why anyone was reaching for a pressor instead of a Cordis or the OR - and, there are a few other instances with small numbers where neither dopamine or norepinephrine is your vasopressor of choice (e.g., anaphylactoid shock, spinal shock).

But, they had good randomization and their treatment groups are very similar.  And what did they find?  No difference.

Well, not completely true - no difference in ICU mortality with a p = 0.07 in favor of norepinephrine and no difference in in-hospital mortality with a p = 0.24 favoring norepinephrine.  So, norepinephrine is favored, but statistically the results are not bulletproof.  I think the trends are reasonable, but it's certainly worth keeping an open mind.  Alternatively, if you wanted to never use dopamine again, you can definitely argue that norepinephrine is no worse.

Secondary outcomes generally trend in favor for norepinephrine with a few reaching significance - although, when you look at 20 secondary outcomes, you're bound to find some significant differences.  The most important difference is the incidence or arrhythmias, primarily atrial fibrillation, which occurred in 24% of the dopamine group and 12.4% of the norepinephrine group at a p = <0.001.

It's an important paper to have around to be on the same page as the critical care colleagues.

http://www.ncbi.nlm.nih.gov/pubmed/20200382

Wednesday, April 20, 2011

Famoditine in Urticaria

Dredged up for Journal Club from The Year 2000 (that was the future, once).

You might scoff at this article because it enrolls a grand total of 25 participants with acute urticaria, ten of which receive diphenhydramine and fifteen receive famotidine.  You might be more impressed to know that this is pretty reflective of the evidence we have regarding H2-blockers in the treatment of urticaria.  Another study from 1993 compares diphenhydramine, famotidine, and cromolyn sodium - and only enrolls 20!

It is mildly amusing to see them report there is no significant difference between the groups when they don't have the power to detect any.  Regardless, our H2 blockers provide some relief, it's likely additive, and they're inexpensive and safe.

The "definitive" study at present supporting our H1 + H2 blocker for acute urticaria or allergic reaction in the emergency department enrolls 91, and it shows diphenhydramine + cimetidine is superior to diphenhydramine alone.

http://www.ncbi.nlm.nih.gov/pubmed/10844490
http://www.ncbi.nlm.nih.gov/pubmed/8329794
http://www.ncbi.nlm.nih.gov/pubmed/11054200

Tuesday, April 19, 2011

Antibiotics Are Unnecessary After MRSA Abscess Drainage

Almost a year old now, but it's been dredged up for Journal Club (spoiler alert: the next two days might have something in common with vis-a-vis dredging).

Small study randomizing skin abscess to placebo vs. TMP-SMX after incision and drainage in children.  I think it's a fair article with decent external validity, as I would say this directly addresses the practice pattern of pediatric emergency physicians, let alone community pediatricians.  The real issue is statistical power for their secondary endpoint and some minor differences between their two groups.  Treatment failures comparing placebo and TMP-SMX are identical - which just goes to show you that the I&D really is the most important element of treating abscesses.  They do a lot of packing!  I suppose I'm almost more surprised there isn't more packing, since that's the commonly accepted practice, but I digress.

The only fire remaining in their argument is that antibiotics will decrease recurrent abscesses.  And, I am willing to give them that - although, I really expect, if they had a longer follow-up period, a lot of those abscesses would return after the antibiotics were stopped because the environment requires eradication.  However, there's a significant difference in the number of each group with a history of recurrent abscesses favoring the TMP-SMX group, which might explain the magnitude of their difference in recurrent lesions within 10 days.

Too small a study to change our practice - although, our practice probably should never have changed from not treating abscesses with antibiotics in the first place.

http://www.ncbi.nlm.nih.gov/pubmed/19409657

Monday, April 18, 2011

Oxy-Free ED

A little bit of a follow-up to yesterday's post on adverse events - and because it was mentioned on EM:RAP a couple months ago.

This is the group up in Washington state that is trying to cut down on the number of narcotics being diverted from their Emergency Department into the community.  It's a nice discussion and something that if you're not already doing something about it, you're not doing enough.  A unified strategy across their entire department helps keep patients and physicians on the same page and standardizes their treatment.  I know at a small critical access hospital at which I work, some patients will call ahead to see which physician is working - since they know they won't be getting their usual fix with certain docs.

Sunday, April 17, 2011

Everything is a Poison...

...when taken in inappropriate amounts.

The NYT reports on a recent AHRQ release that doesn't tell us a lot that's new - more hospital and ED visits are coded with medication side effects - a "50% increase since 2004".  The problem with the lay article is that it focuses on these issues as "medication errors" as some alarming decline in quality in U.S. healthcare.  Part of the problem with this release is that it's simply data - it's not a study or a statistical analysis that attempts to control for other confounding influences - have the number of prescriptions for each of these classes gone up?  What's the average age of these patients presenting with errors (i.e., aging boomers)?  There are a lot of other factors contributing to whether a medication results in an adverse effect, and they aren't just "errors".  The ED data isn't all that insightful, although it is interesting to see how it differs from the inpatient errors.  The #1 culprit for the ED is "Other", which is 261k compared to 118k opiate adverse events - which basically invalidates their data when most of your data points fall into an unknown category.