Is NEXUS dead? Are we admitting too many patients with pneumonia? How useful is the PERC rule? It's all about decision rules on this episode of ERcast. Ryan Radecki from EM LIterature of Note joins us for a review of four papers:

1. Hospital admission decision for patients with community-acquired pneumonia: variability among physicians in an emergency department

2. Diagnostic Accuracy of Pulmonary Embolism Rule-Out Criteria: A Systematic Review and Meta-analysis.

3. National Emergency X-Radiography Utilization Study criteria is inadequate to rule out fracture after significant blunt trauma compared with computed tomography.

4. Are Steroids Effective for Treating Bell's Palsy?

 

Scott Weingart from emcrit.org gives his 2 cents worth on how we should be using the PERC rule. The question is, "How do we decide if a patient has a low pretest probability so that we can select the proper patients in whom to apply PERC?" Scott recommends using the Well's score to decide if the patient is low risk. This gives you validated method of establishing a pretest probability rather than guessing. Although guessing/gestalt works pretty well too. Here is a link to Scott's algorithm.

 NEXUS Criteria

1. No posterior midline neck tenderness

2. No evidence of intoxication

3. Oriented to person, place, time, and event

4. No focal neurological deficit

5. No painful distracting injury

Canadian C-Spine Rules

PERC Rule

Age < 50 years
Pulse < 100 bpm
SaO2 > 94%
No unilateral leg swelling
No hemoptysis
No recent trauma or surgery
No prior PE or DVT
No hormone use

MD Calc Wells Score Calculation Engine

 Bonus Section: Shoulder Dislocation

The Cunningham Technique for shoulder reduction is all the rage. Check out the ERcast tutorial on how it's done. Even though this method can get some dislocated shoulders in like a hot knife through butter, remember that all shoulder dislocations are not the same, nor will all patients be relaxed enough to make it work. I think every emergency provider should be proficient with several reduction techniques.

Here are my top 6

1. Cunningham technique

2. Scapular manipulation

3. Milch/Modified Milch

4. Kocher method

5. Spaso Technique

6. Traction/counter traction with my elbow hooked inside the patients AC fossa while their arm is bent.

The best way to keep up on hot topics in emergency medicine: R and R in the Fastlane 

One of the most important factors driving the medical workup on a well appearing, febrile infant is the prevalence of serious bacterial infection (SBI) . This number changes depending on age and immunization status (pneumococcus vaccine having the most impact in North America.) The higher the likelihood of disease, the more aggressive the workup and treatment.

Prevalence of serious bacterial infection/meningitis by age

• 0-14 days    (pre-vaccine)                             1/10
• 14-28 days                                                       1/20
• 28-60 days (pre-vaccine)                              1/100
• 28-60 days (post-vaccine)                            1/1,000
• 60-90 days                                                       1/1,000-1/10,000
• >90 days                                                           1/>10,000

Pediatric Fever Trivia

Many parents will bring their febrile infant to the emergency department because the fever is not responding to antipyretics. Does response to antipyretics make SBI less likely?

No. This has been extensively studied and no relationship has been found between response to antipyretics and severity of illness or presence of bacteremia.

Yamamoto LT, Wigder HN, Fligner DJ, et al. Relationship of bacteremia to antipyretic therapy in febrile children. Pediatr Emerg Care. 1987;3:223-227. 

Should a chest X-ray be ordered on a febrile child < 3 months of age without respiratory symptoms?

The data to date would suggest no. The likelihood of finding an infiltrate on CXR is extremely low in the absence of ANY of the following exam findings:

• tachypnea > 50 bpm
• cough
• nasal flaring
• stridor
• grunting
• wheezing
• ronchi
• rales
• hypoxia
• coryza (runny nose)

If you see even one of these criteria in a febrile infant or neonate, it's a mandatory CXR, although I still find runny nose a bit of a hard sell indicating a lower respiratory tract infection. Caveat: a child >3 months with a WBC >20,000 should get a CXR to evaluate for occult pneumonia (even if asymptomatic)

ACEP Policy on Pediatric Fever PDF

Bachur R,Perry H,Harper MB.Occult pneumonias: empiric chest radiographs in febrile children with leukocytosis. Ann Emerg Med. 1999;33:166-173. [II]

What age groups of children are at higher risk for urinary tract infection?

0-6 months circumcised males

0-12 months uncircumcised males

0-24 months females

The term fever without a source implies that a child looks well yet still has a fever. When we want to say that a fever is caused by something we can identify on clinical presentation, what are the recognized/acceptable sources?

1. HSV/Gingivostomatits
2. Herpangina/Ulcerative Stomatits
3. RSV
4. Croup
5. Influenza
6. Varicella
7. Viral Exanthum (rash)
8. Enterovirus, coxsackie HFM dz, echovirus, rhinovirus, enterovirus

In the emergency department, it's virtually impossible to identify the exact type of virus causing an upper respiratory infection or gastroenteritis.  A little sniffle or drop of mucous from one nostril doesn't stop the workup, but a copious river of rhinorrhea and a hacking cough in a febrile 3 month old seal the deal.

 The Workup

It all comes down to what tests to order and what treatment to give for the different age groups. The following age based guidelines are based on Dr. Sloas’ approach to the febrile infant as laid out in the podcast. If you disagree with any of this, send us a note or leave a comment on our google voice line. There's nothing like a feud over pediatric fever.

Reference ABNORMAL values in the febrile infant

• WBC<5 or >15, Band/neutrophil >0.2, Bandemia >1,500 mm3, absolute neutrophil count of >10,000
• CSF > 8 WBC or positive gram stain
• UA  > 10 WBC or positive gram stain
• Stool WBCs or heme
• Infiltrate on CXR

Age 0-28 days

Temp > 100.4  or 38C

Workup

CBC, blood cx, cath UA, CXR (I still do it), lumbar puncture, stool studies if needed

Disposition: Automatic admission and antibiotics

Antibiotics

Ampicillin 50mg/kg plus

Gentamicin - Dose varies by age. Give if child is under 9 days old or

Cefotaxime - 50mg/kg. Give if child is 9-28 days.

Possible add ons

Vancomycin  15-20mg/kg

Acyclovir 60mg/kg/day divided q8hrs

The below presume that the child is well appearing, is on the recommended vaccination schedule and does not have an identifiable source of infection

 Age 29-60 days

temp >100.4 F or 38C

Workup

cbc, blood cx, cath UA, possible CXR, spinal tap, stool studies if needed

Disposition:

Admit for anything positive in workup, unable to get follow-up

Antibiotics:

50mg/kg ceftriaxone or

If Workup completely negative, no antibiotics and next day follow-up

 Age 60-90 days

If the temp is <39C, no testing and followup the next day

Temp >102.2F or 39C

Workup

Start with CBC and UA

If both CBC and UA are normal, no antibiotics. Have patient follow-up next day.

 Option 1

If either the CBC or UA are abnormal then proceed with LP and blood culture. And then...

If just the CBC is abnormal, give 50mg/kg ceftriaxone and follow-up next day

If UA is abnormal, give 50mg/kg ceftriaxone, and prior to discharge, initiate oral antibiotics for urinary pathogens (E. coli is the main player) cefixime orTMP/Sulfa. There are many other antibiotic choices for oral agents. The best choice often depends on resistance patterns in your region.

Option 2

There is wide variability in philosophy regarding LP with an abnormal CBC or UA in the 60-90 day age group. Many community ED docs and pediatricians will send blood culture after an abnormal CBC/UA but do not subscribe to the idea that all patients in this cohort need a spinal tap.

Age 3-6 months

Temp >102.2F or 39C

Workup:

Cath UA

Treat if positive

Key Links

The PEM ED Podcast

Andy Sloas' algorithm for pediatric fever

EM BASIC Podcast

Emergency Ultrasound Podcast

Castlefest 2012

As interview with podcast and blogging grandmaster Mark Crislip, MD on vaccinology and influenza.

Mark's website

CDC Flu Site

CDC info for clinicians on antiviral medications and influenza testing

Check out ZdoggMD's video 'Immunize'. Honorable mention winner of the 2011 Disposable Film Festival.

http://youtu.be/-vQOM91C7us

And last, but certainly not least, Mark Crislip's

A Budget of Dumb Asses

I wonder if you are one of those Dumb Asses who do not get the flu shot each year? Yes. Dumb Ass. Big D, big A. You may be allergic to the vaccine, you may have had Guillain Barre, in which case I will cut you some slack. But if you don't have those conditions and you work in health care and you don't get a vaccine for one of the following reasons, you are a dumb ass.

1. The vaccine gives me the flu. Dumb Ass.

It is a killed vaccine. It cannot give you the influenza. It is impossible to get flu from the influenza vaccine.

2. I never get the flu, so I don't need the vaccine. Irresponsible Dumb Ass.

I have never had a head on collision, but I wear my seat belt. And you probably don't use a condom either. So far you have been lucky, and you are a potential winner of a Darwin Award, although since you don't use a condom, you are unfortunately still in the gene pool.

3. Only old people get the flu. Selfish Dumb Ass.

Influenza can infect anyone, and one of the groups who are more likely to die of influenza are the very young. Often those most at risk for dying from influenza are those least able, due to age or underlying diseases, to respond to the vaccine. You can help prevent your old, sickly Grandmother or your newborn daughter from getting influenza by getting the vaccine, so you do not get flu and pass it one to her. Flu, by the way, is highly contagious, with 20 to 50% of contacts with an index case getting the flu.  However, Granny may be sitting on a fortune that will come to you, and killing her off with the flu is a great way to get her out of the way and never be caught.  That would make a good episode of CSI.

4. I can prevent influenza or treat it by taking Echinacea, vitamin C or airborne. Gullible Dumb Ass Cubed Then Squared.

None of these concoctions has any efficacy what so ever against influenza. They neither prevent nor treat influenza. And you can't boost you immune system either. Immunity is not a Jamba Juice. Anyone who says that the immune system can be boosted is also a dumb ass.

5. Flu isn't all that bad a disease. Underestimating Dumb Ass.

Part of the problem with the term flu is that it is used both as a generic term for damn near any viral illness with a fever and is also used for a severe viral pneumonia. Medical people are just as inaccurate about using the term as the general public. The influenza virus directly and indirectly kills 30,000 people and leads to hospitalization of 200,000 in the US each year. Influenza is a nasty lung illness. And what is stomach 'flu'? No such thing, dumb ass.

6. I am not at risk for flu. Denying Dumb Ass.

If you breathe, you are risk for influenza. Here are the groups of people who should not get the flu vaccine (outside of people with severe adverse reactions to the vaccine): Former President Clinton, who evidently doesn't inhale. And people who want to be safe from zombies. If you don't get the vaccine you do not have to worry about the zombie apocalypse, because zombies eat brains.

7. The vaccine is worse than the disease. Dumb Ass AND a Wimp.

What a combination. Your mother must be proud. Unless you think a sore deltoid for a day is too high a price to pay to prevent two weeks of high fevers, severe muscles aches, and intractable cough.

8. I had the vaccine last year, so I do not need it this year. Uneducated Dumb Ass.

Each year new strains of influenza circulate across the world. Last years vaccine at best provides only partial protection. Every year you need a new shot. And we have a new strain this season, H1N1, so you cannot be a parasite on the immunity of others.

9. The vaccine costs too much. Cheap Dumb Ass.

The vaccine costs less than a funeral, less than Tamiflu, less than a week in the hospital.

10.  I received the vaccine and I got the flu anyway.  Inexact Dumb Ass.

The vaccine is not perfect and you may have indeed had the flu.  More likely you called one of the many colds people get each year the flu.  Remember there are hundreds of potential causes of a respiratory infection circulating, the vaccine only covers influenza, the virus most likely to kill you and yours.

11. I don't believe in the flu vaccine.  Superstitious, Premodern, Magical Thinking Dumb Ass.

What is there to believe in?  Belief is what you do when there is no data. Probably don't believe in gravity or germ theory either. Everyone, I suppose, has to believe in something, and I believe I will have a beer.

12. The government puts tracking nanobots in the vaccine as well as RFID chips as part of the mark of the beast, and the vaccine doesn't work since it is part of a big government sponsored conspiracy to line the pockets of big pharma and inject the American sheeple with exotic new infections in an attempt to control population growth and help usher in a New World Order. Well, that excuse is at least reasonable. Paranoid Dumb Ass.

The list of potential badness in the pregnant patient with right lower quadrant pain is long and distinguished, but it often comes down to a simple question, "Does this patient have appendicitis?" The subtext of this question is, "Is this patient going to need a CT scan?" Nobody likes ordering am abdominal CT on a pregnant patient because, no matter how low the statistical risk of damage to the fetus, there is still potential harm from ionizing radiation. As you will see below, the risk of immediate  maternal and fetal harm is far greater than the long term risk of ionizing radiation exposure.

Interview with Ingrid Lim MD at ACEP 2011

Risk of mortality with appendicitis in pregnancy:

In a pregnant patient with unperforated appendicitis, fetal loss is 3-5%. With perforation, fetal loss skyrockets: -30% in trimesters 1 and 2 -70% in trimester 3

Maternal mortality is 1% without  perforation and 4% with perforation

Diagnosis:

Step 1: Ultrasound- more sensitive in the 1st vs. 3rd trimester. Even though it may be inconclusive as far as appendicitis, ultrasound can give valuable information about the fetus, uterus, ovaries, kidneys and gallbladder. If ultrasound doesn't give the answer....

Step 2: MRI without contrast DO NOT USE GADOLINIUM:CONTRAINDICATED IN PREGNANCY If no MRI available...

Step 3: CT with or without contrast depends on your local radiologist. Contrast (IV or PO) is considered safe in pregnancy. Research has shown that contrast does not harm fetal thyroid

RADIATION PRIMER for CT Appy protocol 

Fetal background radiation exposure during 9 months of pregnancy 0.1 rad (1mGy) Teratogenesis threshold: 5 rad (50mGy)

Estimated fetal radiation exposure from CT Appy protocol:

Trimester 1: 2.4 rad (24mGy)

Trimesters 2 and 3: 3 rad (30mGy)

Teratogenesis - fetal death. malformation or developmental delay from in utero radiation exposure. The threshold for a <1% teratogenesis risk is 5 rad (50mGy). The highest risk period is 3-15 weeks. The amount of radiation absorbed from a CT appy protocol is less than the 5 rad teratogenic threshold.   Even with exposure to 10 rads,  there is a 99% chance of no fetal teratogenic effects.

Carcinogenesis-    Most worrisome for childhood cancers such as leukemia. The baseline risk of dying from childhood cancer is  1 in 2000. A 5 rad exposure is believed to increase that risk to 2 in 2000. While that is a doubling of the relative risk, it is still small compared the rate of fetal loss from a ruptured appendix.

Bonus section: Ectopic Pregnancy and HCG levels

Traditional teaching holds that if the HCG does not double in the first 48 hours, consider ectopic. But many patients do not follow this curve. With  the development of more sensitive assays, a minimum rise of 53% over 48 hrs is acceptable. 3% of ectopic pregnancies can have a negative serum HCG

Two theories: 1.     Have to have a viable trophoblast to produce HCG, no trophoblast…no HCG    2.  Ectopic died then ruptured

Bottom line, if patient looks sick and there is a lot of free fluid in the pelvis –go to surgery

Written Summary:  Justin Arambasick MD  Akron General  Medical Center and Rob Orman MD

A good article on MRI uses in pregnancy

Research and Reviews in Emergency Medicine and Critical Care is an amazing project thatbrings together physicians from across the globe to find the hottest medical articles on the planet. This is an international collaboration with  contributers  from Ireland, UK, South Africa, Australia and the United States. If you want to see what's making waves in the medical world and stay up to date on current trends in emergency medicine and critical care,  click here to go to R and R post 1.

From the land down under, a must have for every ED: Link to The Emergency Eye Manual

It's deeply rooted medical dogma that spinal tap needs to follow a negative CT when evaluating patients for subarachnoid hemorrhage. New literature has come out to challenge that idea. We talk with Scott Weingart of emcrit.org and Ryan Radecki of Emergency Medicine Literature of Note about a 2011 BMJ paper that looks at the sensitivity of computed tomography when performed within 6 hours of headache onset. 

Keeping with the neurology theme, what's the story with awake blunt trauma patients with a negative cervical spine CT who still have neck pain. Do they need an MRI?

Also...

Broome Docs in Western Australia

Justin Arambasick gets published in EP monthly

Zdoggmd has been busy

ERCAST Rant-Off 2011

It's open mike time for whatever get's your goat (in medicine, that is). Featured rants...

Cliff Reid of resus.me: The Propofol Assassins

Dave Peaslee: "Do you know what medicines you're on, sir?"

Andy Neill of emergencymedicineireland: Are we thinking about PE the right way?

Mike and Matt from the emergency ultrasound podcast: US vs CT for appendicitis

Resident Jim: How I feel about attendings who do a full H&P before I get in the room

Dan Gromis: Can you really be allergic to iodine? I think not!

Gerry O'Malley: Why do we teach residents defensive documentation?

Steve Ayers: When can you really say someone has HTN?

Mike Jasumback: Wants an emergency medicine forum. Email him at EMforum@live.com

Haven't subscribed to ercast in itunes yet? Here's how.

How important is it to get a perfect reduction of a distal radius fracture in the ED? Is it even worthwhile?

Pro

-Pain is improved when a severely displaced fracture is reduced and immobilized.

-The ED has sedation capabilities that the orthopedist's office does not. If we can get good anatomic alignment in the ED and save a trip to the OR, we've benefitted the patient

-You are treating the patient for their presenting complaint

Con

-A significant portion of reduced fractures will fall out of reduction

-They are a huge time and resource sink. Time to reach NPO status keeps a bed occupied. The sedation and splinting involve multiple staff members. A nurse is taken away from other ED patients for as long as the patient needs close monitoring

-Many of these patients may not actually benefit from reduction.

Do you like to reduce Colles fractures? If so, have at it. They're one of my favorite procedures and I rarely pass up the chance. But there is no fault in splinting and referring to the orthopedist as long as the skin and neurovascular exam are intact. You just need to explain to the patient/family why you're not fixing a deformed wrist.

Written Summary:  Justin Arambasick MD  Akron General  Medical Center

Consult with Hans Moller, MD

Does a mild to moderate (< 35˚) nonarticular fracture of the distal radius have to be reduced?
Not necessarily. Many countries in Europe do no perform surgery or reduction on
these, and a variety of low powered studies have not shown functional benefit
in doing so.

Is there a benefit to doing an ED reduction?
Yes, patients whom have had a reduction in the ED and show up in the orthopedic
follow up clinic have in general better pain control and less skin changes.

When should a patient follow up with orthopedics after an ED reduction?
7-10days

Does intraarticular involvement necessitate a trip to the OR?
Not necessarily.  These fractures are at higher risk for subsequent arthritis, which can be mitigated by surgery (but not completely prevented). The problem with these is that the pieces of the fracture tend to drift apart, increasing the chance of an unfavorable outcome.

What is radial shortening?This refers to the length of the radius comparing the carpal articular surface of the ulna and the lunate fossa of the radius. A line drawn across the end of the ulna should be at the same level as the radial lunate fossa. If the lunate fossa is behind (proximal to) this line, the radius is shortened.

 Radial length

Radial Shortening (yellow arrow)

What is the purpose of finger traps?
To elongate the shortened radius. Hans prefers placing the thumb and
index finger in the trap and separating them by a 3 inch roll of Webril, thus
elongating the radius and providing ulnar deviation.  Place splint on while
still in trap.

What are the hallmarks of an adequate fracture reduction?
<2mm articular step off
<20 degrees of volar angulation
<3mm of radial shortening
With these parameters, the functional outcome should be the same as someone who has had surgery.  Surgery has quicker return to full function than casting.

Papers Discussed
Injury. 2010 Jun;41(6):592-8. Epub 2009 Dec 2.
The efficacy of closed reduction in displaced distal radius fractures.
Neidenbach P, Audigé L, Wilhelmi-Mock M, Hanson B, De Boer P.

J Bone Joint Surg Am. 2010 Aug 4;92(9):1851-7.
Distal radial fractures in the elderly: operative compared with nonoperative treatment.
Egol KA, Walsh M, Romo-Cardoso S, Dorsky S, Paksima N.