Tue, 18 February 2014
Cardiac arrest. It seems so easy. Just follow the algorithm on the reference card, and all cardiac arrest issues will be solved. The truth is that codes can be messy, chaotic and scattered. On this episode of ERcast, we hear from the RAGE podcast experts on how to take control of the room and run an effective resuscitation.
The medicine isn't always the hard part. Being an effective leader, communicating well, and making things happen are often the bigger challenges. And speaking of Making things happen. Click that link for one of the greatest medical lectures. Ever.
Adenosine vs Verapamil Articles
Adenosine versus Verapamil for termination of SVT (AVNRT)
Sat, 8 February 2014
Which is more effective for pain and fever control: Acetaminophen or Ibuprofen? Should a patient in the emergency department with upper GI pain be started on an H2 blocker or a proton pump inhibitor? Special guest Anand 'The Swami' Swaminathan joins ERCast to explore these and many more medical quagmires.
Bonus segment: How can a medical students present themselves well during critical rotations? In this case, we are talking about emergency medicine rotations.
Acetaminophen versus Ibuprofen
Perrott DA et al. Efficacy and safety of acetaminophen vs ibuprofen for treating children’s pain and fever: a meta-analysis. Arch Pediatr Adolesc Med 2004; 158(6): 521-6.
2004 meta-analysis - summarized the findings from 17 randomized, controlled trials comparing the two drugs in children <18 years of age. Three studies involved pain, 10 involved fever, and all 17 involved safety.
1. Pain – no difference between ibuprofen 4-10 mg/kg vs. APAP 7-15 mg/kg
2. Fever – ibuprofen 5-10 mg/kg superior to APAP 10-15 mg/kg (at 2 hours and more pronounced at 4-6 hours)
15% more children were likely to have reduced fever with ibuprofen compared to acetaminophen.
When selecting for studies using only the 10mg/kg dose of ibuprofen, there was a doubling of the effect in support of ibuprofen.
Safety: there was no evidence that one drug was less safe than the other (or placebo). The authors determined that this data was inconclusive and that more large studies would be needed to identify small differences in safety
Pierce CA et al. Efficacy and safety of ibuprofen and acetaminophen in children and adults: a meta-analysis and qualitative review. Ann Pharmacother 2010; 44(3): 489-506.
First meta-analysis looking at the question in adults.
Qualitative review revealed that ibuprofen was more effective than acetaminophen for pain and fever reduction, and that the two were equally safe.
From the quantitative data, the authors found that for pain, ibuprofen was superior in children and adults. For fever, ibuprofen was superior in children, but conclusions could not be made for adults due to insufficient data.
What about alternating acetaminophen and ibuprofen?
Malya RR. Does combination treatment with ibuprofen and acetaminophen improve fever control? Ann Emerg Med 2013; 61(5): 569-70.
1. Identified 4 studies that the author deemed high-quality and relevant to emergency practitioners.
2. Three of the four studies found that the combination was more effective at reducing fever than either alone.
One study that looked at alternating regimens over 24 hours found that 6-13% of parents exceeded the maximum number of recommended doses (Hay, 2008).
There is suggestion that the two drugs could act synergistically to cause renal tubular injury; however, acetaminophen and ibuprofen have different pathways of metabolism, and adverse effects in patients taking both have only been described in rare case reports.
EM Lyceum Review of APAP (acetaminophen) vs NSAIDS (ibuprofen). This review also includes a breakdown of PPIs vs H2 blockers, medical treatment for vertigo, and calcium channel blockers versus beta blockers for atrial fibrillation with rapid ventricular response (RVR)
Check out the RAGE podcast. In this episode of ercast, we discuss a recent round table on managing SVT (AVNRT) with verapamil versus adenosine.
Mon, 20 January 2014
Interview with hematologist Dr. Tom Deloughery about a smattering of clotting quagmires...Superficial Thrombophlebitis, Recurrent Pulmonary Embolism, Calf Vein DVT, Clotted PICC Lines, Starting (loading) dose of warfarin, low molecular weight heparin, widowmaker clots.
Quandary 1. Recurrent pulmonary embolism
Your patient is on warfarin, INR is therapeutic and has another PE. What do you do?
Make sure it’s truly recurrent. If it is...
First dose of warfarin
1. How long to you need to wait to start warfarin after the first shot of LMWH? You can start both meds at the same time.
2. Is there a need for a loading dose of warfarin? Sort of....Dosing and effect are unpredictable. As a general rule, Tom gives young and otherwise healthy patients 10mg as a first dose. Over 65 or young and frail, first dose 5mg.
3. If your patient needs to restart warfarin after being off it for a while, do you need to bridge with LMWH until the INR is therapeutic? In the setting of DVT and PE, yes. In atrial fibrillation, you probably don’t .
Can clot in the saphenous vein progress to DVT? Yes. 5-10%. Non saphenous vein clots progress to DVT at a rate of about 1%. As saphenous vein clot gets closer to the femoral vein, risk rises of it becoming a deep clot, but there are also perforator veins all along the saphenous vein that connect it to the deep system. Clot can connect from the superficial (saphenous) vein to deep vein through a perforator at any point, but it’s less of a worry than deep propagation directly into the femoral vein near the groin.
Treating superficial thrombophlebitis needs to take into account the ‘thrombo’ (clot) and ‘itis’ (inflammation)
NSAIDS decrease rate of inflammation and clot extension
Therapeutic vs prophylactic LMWH: both decrease rate of inflammation and clot extension - outcomes are equal, so prophylactic LMWH is preferred (once a day, lower dose)
Small, under 5-7cm and not proximal (not upper half of thigh) NSAIDS
Larger than 5- 7cm or proximal, prophylactic dose of LMWH or fondaparinux (40mg daily)
Duration of therapy
There is uncertainty as to the optimal duration of therapy. Tom treats for two weeks. If patients are still symptomatic, treat for another two weeks.
Upper extremity thrombophlebitis
It is thought that upper extremity superficial thrombophlebitis has a more benign course. Treat with NSAIDS and hot packs. If this isn’t working, transition to LMWH.
What should you do with a PICC line clot?
Anticoagulation does not help with recannalization. Pull the line.
Putting in a new PICC right away - high rethrombosis rate.
Calf vein DVT
15-30% will grown and cause PE. Follow up ultrasound to check for extension is an option.
Unless there is a contraindication, treat with anticoagulation. ACCP recommends 3 months of treatment, Tom treats for 6 weeks.
Factor V Leiden mutation
9% prevalence in Portland, OR. Mostly a caucasion disease. Raises risk of first clot 3 fold (more DVTs than PE). Having this mutation does not increase risk of DVT recurrence.
Bonus point of the day
The SUPERFICIAL femoral vein is a DEEP vein. Perhaps the worst anatomic name ever. If you get a report that your patient has clot in the superficial femoral vein, that is a DVT, not superficial thrombophlebitis.
Mon, 20 January 2014
The 4th anniversary of ERcast recognizes some of the luminaries who have helped and inspired me since the show's inception.
Tue, 17 December 2013
We learn about the MUD PILES, the causes of anion gap acidosis, as medical students. And it gets even further drilled into us in residency. But sorting out a gap acidosis can be real challenge, even with a nifty mnemonic. To help us get smarter in understanding some of the nuance of gap acidosis, Sean Nordt, MD, PharmD.
Case: Alcoholic, diabetic with a blood glucose of 295, bicarbonate of 12, and an anion gap 28. Is this alcoholic ketoacidosis (AKA), diabetic ketoacidosis (DKA), toxic alcohol, something else? What is the cognitive process for sorting out this anion gap acidosis?
Nordt: Without additional history, send...
Case continues: The patient has a normal mental status. Heart rhythm is sinus tachycardia in the low 100s. To treat this sinus tachycardia, he gets the sinus tachycardia antidote - 3 liters of normal saline. Since AKA (a starvation and volume depletion ketosis) is high on the differential diagnosis, he also gets a hamburger and apple juice. His labs are rechecked and few hours later and his bicarbonate is unchanged at 12 and anion gap drops slightly from 28 to 24.
How fast should the anion gap and serum bicarbonate to correct in AKA?
Nordt: It should start to improve in 1-2 hours and takes about 5-7 hours to reverse. If the anion gap and bicarbonate aren’t improving (or getting worse) in an hour or two, think about an alternate diagnosis.
Case continues: Since there’s not much improvement in the gap acidosis after several hours of re-feeding and fluid resuscitation, maybe this is not a case of AKA. Could it be DKA? Probably, but it could also be one of the many other causes of anion gap acidosis. With a persistent gap acidosis, or maybe one that’s hard to figure out, are there clues to look for or other tests that can help?
Let’s go through the different things that we use, or tests we order, to sort out the gap.
Working through the MUD PILES on this patient...
Methanol - Still possible
Uremia- No. Renal function normal
DKA- Still possible
P- Propylene Glycol. Possibly. Propylene glycol gets metabolized to lactic acid. Excessive propylene glycol from medications is unlikely in the ED (unlike the ICU where patients get many injectable meds), but can be found in pet friendly antifreeze.
INH- No Iron- No Infection-No evidence of this
Lactic acidosis- Still possible. He takes metformin but renal function is normal
Ethylene Glycol - Still possible
Salicylates- Salicylate level negative
The remaining MUD PILES...
How do we figure out the answer? We don’t always have to have the right answer in emergency medicine, but we shouldn’t be wrong.
Thu, 14 November 2013
What do lung nodules have to do with emergency medicine? Weʼd like to see ourselves as full time resuscitationists and while thatʼs one of our master skills, much of our job involves taking care of non-critical patients and, even more so, having conversations with patients and their families. But arenʼt pulmonary nodules someone elseʼs problem, like the pulmonologist? Yes, and no. The pulmonologist is going to manage things in the long term, but the overwhelming majority of nodules are going to be incidental findings that land in your lap.
You get a phone call from the radiologist on a CT chest, “Thereʼs no PE or sign of dissection, but thereʼs a 5mm non-calcified pulmonary nodule in the right upper lobe” What does that mean? Do you need to pay attention to it? Can you ignore it? What do you tell the patient?
The conversation often goes something like this, “Good news Mr. Jones, we donʼt see a blood clot and, oh by the way, the radiologist saw a small nodule.” For you, someone who is used to getting reports of an incidental pulmonary nodule, itʼs no big deal. For the patient, what they heard is, “You have cancer.” That may sound like hyperbole, but itʼs most patientsʼ first reaction.
Mr. Jones may or may not have cancer and Mr. Jones may or may not ask you questions. We donʼt want to do is to induce fear in the patient by our ignorance but we also donʼt want to dismiss the findings and ignore a possible malignancy.
Is this a bad nodule?
Who needs follow-up and when should they get it?
This comes down to risk and benefit. Risk that this nodule is malignant, the benefit of follow up imaging versus the risk of extra radiation, unnecessary biopsies, surgeries, anxiety, and medical bills. While it’s not well known in emergency medicine, The Fleischner Society is a group in radiology that develops an evidence based consensus guideline on how to follow up pulmonary nodules.
Nodule size and patient risk factors are the principle elements that determine timing and type of follow-up study needed. There are two main pieces of the Fleischner Criteria that are germane to emergency providers:
These guidelines suggest that the likelihood of a small (≤4mm) nodule being cancer in low risk patient is so low that no further follow up is needed. Will some of these nodules turn out to be cancer? Yes, but striving for a zero miss rate in this group is not risk-benefit favorable. The likelihood of the patient having negative sequelae (radiation, unnecessary biopsy, surgery, financial hardship) is greater than the chance of the nodule being cancerous. Itʼs analogous to striving for a 0% MI miss rate. Cost far outweighs benefit.
The Other Side of the Fleischner Coin
Not everyone follows the Fleischner guidelines. Some radiologists recommend follow-up imaging, or at least discussion, for every patient with a newly diagnosed nodule. Pulmonary nodules are a complex topic with multiple factors and variables that dictate the best course of action (or no action). These patients need follow up, preferably with a pulmonologist, to discuss risk level and decide what to do next. When weʼre talking about a one millimeter difference dictating a follow up scan versus doing nothing, one of my colleagues who is a chest radiologist, has this to say, “Depending on how much coffee Iʼve had to drink, I can measure the same nodule 20 times and have it be different every time, so trying to make separate recommendations for nodules that are ≤4mm or 4-6mm is silly to me. “
Tips for communicating with patients
What are you going to say to the patient?
Here are some example scripts for delivering the news of a newly diagnosed nodule...
“Mr Jones, good news, there's no blood clot. The radiologist did mention that he saw a small spot on your lung. The medical term for it is a nodule. It's 5mm, which is about half the width of your little finger or the size of a pea. We see these all the time and 95% turn out to be completely harmless so I don't want you to lose any sleep over this. You will, however need to make sure someone takes a look at this again with a CAT scan to make sure it's not growing. Iʼm going to refer your to our pulmonologist, a lung specialist, who is an expert in lung nodules and will help guide you the rest of the way.”
Maybe Mr. Jones is low risk.... “The chance of this nodule being anything serious is extremely low. The nodule is small, you donʼt smoke and youʼre young. The risk isnʼt zero, but itʼs pretty close. I still think you should follow up to discuss all of the options, but in all likelihood, this will not cause you any problems.”
The overwhelming majority of pulmonary nodules are benign. The bigger they are, the higher the chance of malignancy. There is debate as to whether a very small lung nodule in a low risk patient needs follow up at all. Should an emergency provider make the call that no follow up is needed? I think there is too much uncertainty in sorting out all of the variables that go into risk factor assessment. I refer all patients with newly diagnosed nodules for follow up, risk stratification, and further discussion with their PCP or a pulmonologist.
Patients almost always have questions about the significance of their newly diagnosed pulmonary nodule. What they really want to know is if they have cancer. You canʼt know that looking by at a nodule one time. For a small nodule, itʼs about how it grows (or doesnʼt) on repeat studies. The things that make cancer more likely and follow up more urgent include size >4mm, age over 35, history of smoking, and nodules that are not completely calcified.
In the end, it may be cancer, but chances are, your patient is going to be just fine.
Bonus Section... Even more information about pulmonary nodules!
Historically, all patients with non-calcified nodules were recommended to get follow-up chest CTs for 2 years. This was based on the pre helical CT era when most pulmonary nodules were found on chest x-ray. By the time a nodule is seen on CXR, itʼs often big. The old ACCP recommendation for indeterminate solitary nodules was follow up CT at 3-, 6-, 12-, and 24 months. Thatʼs five chest CTs (including the original study), no matter what. When you consider that upwards of 51% of smokers over age 50 have pulmonary nodules, that is a lot of negative CT scans, radiation, unnecessary biopsies, surgeries, anxiety, and money spent. With our ability to diagnose smaller nodules, we needed to change our thinking about what to do with them. Thatʼs what the Fleischner recommendations addressed. Itʼs not one size fits all.
Does it make a difference if the nodule is measured on CT or Chest X-Ray?
These measurements apply only to CT scans. CXR is too inaccurate. The work-up for nodules found on CXR varies depending on the scenario. The first step is to try to get old films to see how long it's been there. If no old films are available, depending on nodule features and clinical story, the patient needs either a CT scan or a short-term follow up CXR (4-6 weeks) to see if it persists. Sometimes it's tough to tell if a nodule is calcified on CXR. If it is obviously calcified, it doesn't need any follow-up.
What does calcification in a nodule suggest? Calcification in a small nodule suggests benign etiology. Mostly. A partially calcified nodule or one with eccentric calcification needs followup. Malignancies, like scar carcinomas (from old granulomas), and mucinous adenocarcinomas can have small calcifications.
How should you think about terms like ground glass, semi-solid, and solid? Does appearance make a difference when it comes to determining nodule behavior?
Thu, 31 October 2013
When a trauma arrest rolls though the door, chaos often ensues. But it doesn't have to be that way. Scott Weingart returns to ERcast to share his thoughts on how to run a rational blunt trauma arrest resuscitation when you are working by yourself or with limited personnel.
Scott W's recipe for blunt trauma arrest
Check for a pulse when the patient arrives. If they’re pulseless, they’re in arrest....
The fundamental philosophy: Do only those actions that will make a difference in your patient's survival
Step 1. Airway
Control the airway. If your patient is already intubated, you're done. If not, intubate or place a supraglottic device.
Step 2. Breathing
Perform bilateral finger thoracostomies. There are very few things in a blunt trauma arrest that you can reverse and save a life. One of those is a tension pneumothorax. If there is no rush of air or improvement of condition, proceed to step 3.
Step 3. Circulation
Perform a bedside cardiac echo.
If there is no cardiac activity, the resuscitation is over and the patient is dead.
If there is cardiac tamponade, remove the blood. In trauma, this usually means cracking the chest (ED throacotomy) and delivering the heart from the pericardium. You can try a pericardiocentesis, but that is less likely to be successful.
If there is cardiac activity, your patient is in hemorrhagic shock. Give blood with massive transfusion protocol.
Step 4. Look for sources of bleeding
Did your patient exsanguinate from a scalp laceration?
Is there bleeding into chest? You would have discovered this with finger throacostomy
Is there bleeding inside the peritoneal cavity? Perform a FAST ultrasound
Is there bleeding in the retroperitoneum? Squeeze the pelvis and bind if there is mobility
Is there bleeding from or into the extremities?
Is CPR beneficial in a trauma arrest?
This is such deeply entrenched dogma that I was shocked when Scott suggested that there is no functional reason that closed chest compressions will help in a traumatic arrest. But when you break down the reversible causes of blunt trauma arrest, it makes sense...
Exsanguination: you cant pump an empty circulatory system
Tension pneumothorax: you can’t pump with a zero venous return system
Pericardial tamponade: you can’t pump a heart that can’t accept any more blood
That being said, I still do CPR in a trauma arrest, but don't let it interfere with critical procedures. What do you think?
Fri, 25 October 2013
In this minicast, The Weingart Strikes Back!
Scott Weingart has some issues with our last episode on managing blood pressure in acute ischemic stroke. But the Swami doesn't take it lying down and has a few things of his own to say.
Join Scott, Swami and Rob at the Essentials of Emergency Medicine Pub Crawl on November 4, 2013 at 7pm
Blu Restaurant 747 Market St, San Francisco, CA
Mon, 14 October 2013
How do you manage blood pressure in acute ischemic stroke?
Should you give thrombolytics up to 4.5 hours after symptom onset?
When do you decide that a CVA is actually a TIA?
What is the age cutoff for using thrombolytics in acute ischemic CVA?
And... What's up with the new American College of Emergency Physicians clinical policy on TPA in stroke?
Sun, 1 September 2013
Video laryngoscopy has changed the game in in airway management, but has it made direct laryngoscopy obsolete? Anand "The Swami" Swaminathan joins Ercast to discuss the controversy and share some of his research.
Links Discussed in this episode