Friday, June 15, 2012

How to Be Popular at the Beach

The summer is a great time for swimming - and, luckily, there's an evidence-based systematic review of treatment of jellyfish stings available from Annals of Emergency Medicine.  Unfortunately, it's only the relatively benign and inconvenient species from North America, rather than the life-threatening species found more commonly in the southern hemisphere.

Literally, everything has been tried on jellyfish stings in an attempted in treatment, from vinegar, to ammonia, to ethanol, to meat tenderizer, to magnesium chloride, and the list goes on.  Essentially, the attempted treatments fall into two camps - wash off the nematocysts without inducing discharge, or simply to treat the pain and tissue damage from the venom itself.

The American Red Cross First Aid consensus suggests the use of vinegar - which, according to this review, induces nematocyst discharge in everything but some Physalia species.  The real answer is...no single agent reliably inactivates nematocysts from every organism.  The authors recommend simply using readily available saltwater to wash the affected area.  For post-envenomation pain, topical anesthetics such as lidocaine and hot water were found to be most reliably effective.  Given the limited availability of anesthetics to laypersons, the best treatment is likely to be hot water submersion to help inactivate the toxins.

"Evidence-Based Treatment of Jellyfish Stings in North America and Hawaii"
www.ncbi.nlm.nih.gov/pubmed/22677532

Wednesday, June 13, 2012

A Little Proof of Harms from CTs

It is popular to worry about the harms of CT scans in small children.  A retrospective Swedish study suggests decreased intelligence.  And, our models based on nuclear weapon exposure data combined with dummy CT exposure suggest these scans are likely to result in an increased risk of malignancy.

This is another retrospective study in the National Health Service of Britain comparing malignancy outcomes with their exposure to CT in childhood.  The scary headline: CT scan radiation triples the risk of leukemia and primary brain malignancy.  Of course, triple the risk is essentially 1 additional case of leukemia and 1 additional case of primary brain malignancy in the first 10 years after exposure.  So, this is potentially another study you can use to discuss the Number Needed to Harm with families when discussing the need for CT radiation in pediatric cases.

Now, whether articles like this trigger a wave of legal trolling for malignancies preceded by CT remains to be seen....

"Radiation exposure from CT scans in childhood and subsequent risk of leukaemia and brain tumours:  a retrospective cohort study"
http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(12)60815-0/abstract

Monday, June 11, 2012

News Flash: Diagnostic Tests Take Time

It's a little more insightful than my cynical title indicates, but it is, essentially an article that tries to quantify what we already know - blood tests, MRI, and CT all add to ED length-of-stay.

While the article isn't specifically earthshaking, it interests me in the context of patient flow through the Emergency Department and the utilization of finite ED resources.  Every ED has a waiting room - and, if you're like me, sometimes you look at the board and there are 34 waiting - on a good day.  In that sense, one becomes acutely aware of the value of space in the ED with which to evaluate new patients.  If blood tests and imaging tests are adding over an hour to ED LOS for each of your bed, then it would seem prudent to minimize those tests whenever possible.  It might also, perhaps, even be feasible to consider "standard of care" to be a malleable concept based on a need to ration testing specifically to increase patient flow, balancing the risks of diagnostic uncertainty against the risks of prolonged waiting room times.

Just brought to mind some interesting issues.

"Effect of Testing and Treatment on Emergency Department Length of Stay Using a National Database"
www.ncbi.nlm.nih.gov/pubmed/22594356