EMERGENCY MEDICINE UPDATE

SEPT 12 I like to start out EMU each month with a useful article that goes against the grain but this one was too interesting to pass on for the number one spot. And it comes from JEM 41 (2)124. MRSA is the rage these days and they studied their ED for MRSA on all sorts of surfaces- is this monster going to be on telephones, computers, desktops, in your living room telling you what you can watch on TV etc etc? The answer is actually no. They only found it in one place. However, do not jump on this study so fast. They only tested forty places and the one place that was positive was multi drug resistant. Furthermore, this study was done back in 2006 why it took five years to publish-is beyond me- and MRSA was a lot less prevalent in the community in those days. So in my opinion this guy is just weaiting to mug you even in the ED. And while you are probably carrying around this bug for years (interesting idea for a study) - protect your patients by washing your hands and changing your clothes often (No not in the middle of the ED). However that last recommendation is flawed also (no; not that part about changing in the middle of the EDunless you are really cute). This article compared newly washed short sleeve white jackets with the old lab coat you have been wearing every day for about three years. The MRSA rates were similar after an eight hour work day
1)
41 1

EMERGENCY MEDICINE UPDATE

meaning that either this bug side taking over or just that we are all infected (J Hosp Med 6(4)177) TAKE HOME MESSAGE: MRSA may not live on ED surfaces but this study cannot tell us 100%. Resistance is futile!

Drip and Ship- can you do it? Question to ask firstwhat am I talking about. If you believe in TPA for new CVAs so do you really need to keep them in the ED until the process is completed? Well in this study they all did well but the authors do admit it was a tiny study (ibid 135). However, since the TPA guidelines are so restrictive these patients are generally very healthy and have a low risk of bleeding in any case. TAKE HOME MESSAGE: You probably do not need to hold stroke patients getting TPA in the ED until the drip is done.
2)
41 2

EMERGENCY MEDICINE UPDATE

The details of this case are really not so important but the concept is. This poor fellow spent his hard earned money on Percocet to get him self a little whiz. What he ended up with was a wide complex tachycardia from Propafenone which was substituted for the Percocet (I guess he still got his whiz). I do not know if he got his money back but the key is that there are a lot of drugs out there that are spiked with other impurities or are substituted with other often more dangerous drugs. (ibid p172) You should have someone to speak to about this, but our go to guy in Israel is Dr. Arieli who gives me his ideas on the magnitude on the subject This article came out of Einstein Philly whose program recently became subscribers and I wanted to say hi and congratulations. And just for those who doubted- what you are reading is the real EMU even if you did buy it on the street. TAKE HOME MESSAGE: Caveat Emptor- if you are buying meds or drugs from unapproved sources. Are you? Probably explains why you are undressing in the middle of the ED. Now here is Mickeys take: Public health danger from counterfeit medications and
3) adulterated food supplements
By Mickey Arieli Pharmacist, Director of Division of Enforcement and Inspection, MOH, Israel AlinaPoperno Pharmacist, MPH, Division of Enforcement and Inspection, MOH Israel

Counterfeit medicines and supplementsposean enormous public health threat. The World Health Organization estimates that 10% of global pharmaceutical commerce is in fakes [1].Apart from counterfeit prescription medicines there are products labeled "natural supplements" that are illegally

41 3

EMERGENCY MEDICINE UPDATE

adulterated with active pharmaceutical ingredients, such as, sibutramine,PDE-5 inhibitors(sildenafil,tadalafil and vardenafil), lidocaine, benzocaine, benzodiazepines, SSRIs, phenolphthalein and more. The most common weight loss and anti-impotence adulterants found on Israeli market are sibutramine and sildenafil. As a consequence of sibutramine adulteration, a few dozen people, mainly young women, were hospitalized due to cardiovascular events, some of which were life-threatening.In addition, there were hospitalizations following sever psychiatric events associated withthe use of sibutramine adulterated weight-loss natural products.Health risks of PDE-5 inhibitors adulterationsare vast, they include, headaches, sudden hearing loss, heart attack, arrhythmias, hypotension etc. The greatest risk isinpatients, to whom PDE-5 inhibitors are contradicted so they are turning to natural remedies for impotence or when concentration of the active ingredient/s significantly exceeds therapeuticlimits. Moreover, in recent years, clandestine laboratories replace known pharmaceutical compounds with their chemical analogues. In many cases, these analogues are significantly more potent than original compounds and they are much more difficult for detection. In the past few months, our division has confiscated quantities of new and dangerous "natural" food supplements. Our toxicological analysis discovered in a "natural" product called "ManUp" a combination of sibutramine and sildenafil. We have also received reports regarding two new natural products, which claim to lower blood sugar "Balins" and "Diabetico". Toxicological analysis revealed that these "natural" products contain a high dosage of a potent sulfanylurea drug. Recently, anti-cancer drug, Avastin, found to be devoid of an active ingredient (Bevacizumab) so in a number of clinics in the US cancer patients were not actually receiving a life-saving treatment. The extent of the problem and the amount of harm from counterfeit drugs are underestimated, since detection and clinical reports are limited. Increasing the awareness among physicians of possible natural supplement that contain active pharmaceutical substances and effective cooperation between health care professionalsare crucial for combating the illicit pharmaceutical trade. We encourage cooperation and communication between health professionals and our division. We can be contacted through following emails: Mickey.a@moh.health.gov.il (cell phone 972-506243137), alina.poperno@moh.health.gov.il . References:

41 4

EMERGENCY MEDICINE UPDATE

1. Newton PN, White NJ, Rozendaal JA, Green MD. Murder by fake drugs.BMJ. 2002 Apr 6;324(7341):800-1.

This will never fly in the ED, but perhaps will help our FP readers. If a pregnant woman knows her blood type and Rh status, there is no need to repeat it unless you are about to transfuse her.(ibid 223) While there were no serious misses on the Rh side (one woman thought she was negative when she was positive) the few misses on the blood type may have serious consequences. Use it as a guide however. TAKE HOME MESSAGE: Probably do not have to repeat Rh status in the clinic in pregnant patients if the patients know their status. 5) I really do not know how EMS folks are trained- and when we have our EMS roundtable we will know more- but in my country the EMS guys get no driving instruction. In this article EMS deaths were most commonly due to aircraft fatalities and vehicle crashes. They often have strains and sprains as causes of non fatal injuries but I am unaware of any conditioning programs that EMS guys do in my country. In short it is a dangerous job. (J Prehosp Care 15(4)511 ) Despite all this, I am unaware of any fatalities in my country. TAKE HOME MESSAGE: EMS personnel are exposed to musculoskeletal injuries and vehicular injuries that make
4)

41 5

EMERGENCY MEDICINE UPDATE

this a possibly unsafe occupation. This is getting a little dry so let's dedicate this issue to quotes from some of our favorite doctors- the MASH folks: I just don't know why they're
shooting at us. All we want to do is bring them democracy and white bread. Transplant the American dream. Freedom. Achievement. Hyperacidity. Affluence. Flatulence. Technology. Tension. The inalienable right to an early coronary sitting at your desk while plotting to stab your boss in the back. (Hawkeye Pierce) Not funny enough? here is one from Frank Burns: Your picture's in my wallet and I'm sitting on it. And if that isn't love, I don't know what is. 6) No article here, but I just saw this case and think it is

interesting. I got an 81 year old fellow taking colchicine, aspirin, enalalpril, norvasc and bisprolol for hypertension and gout. He takes nothing for his hyperlipidemia. His blood tests reveal a WBC of 1.52 where it was normal (8.1) three months ago. His hemoglobin is stable at 11.9 Chemistry reveals a sodium of 138, potassium of 4.4, urea of 79 and creatinine of 2.1 which is new. He has less than 500 neutrophils but they are normal. There is no fever. Not such a hard case, but ... 7) Post thrombotic syndrome occurs in patients with DVT who get better with anticoagulation but remain with swollen legs with a 3-5% risk of ulcers. We have all seen such patients and there is little we have to offer them- but this article gives a simple although relatively unproven way of dealing with DVT that avoids this syndrome- catheter
41 6

EMERGENCY MEDICINE UPDATE

directed thrombolysis. However good trials are undergoing and the small trials were pretty impressive- dropping the rate of Post T syndrome by 50%. Seems very simple but I don't know anyone who is doing this for DVT (BMJ 2011). TAKE HOME MESSAGE: Catheter directed thrombolysis may be therapy to prevent post thrombotic syndrome in DVT patients. 8) This actually happened to me! I had a patient that I put in a CVP on the right side and intubated and then did a chest film, and there was a massive pneumothorax- but on the left side. Do you put in a chest tube?? No- this was a skin fold that was nicely picked up by the radiologist- but if you aren't sure, do a CT. This article echoes this and says that skin folds tend to disappear before they get to the margins. (Int Med 50(16)1775 ). I lost the original film but

41 7

EMERGENCY MEDICINE UPDATE

here is something similar : OK, guys- do not get on my case- I know this is a picture of a skin fold and a pneumothorax- but that doesn't change the point. (Courtesy of USUHS) TAKE HOME MESSAGE: Blebs and skin folds can cause pneumothorax pictures- CT if you aren't sure. 9) I liked the idea but as usual it leads no where. Troponin can tell us about the MI in patients with normal EKGs, so it would follow that there should be good markers for TIA just like with the heart. The problem is that TIAs by definition cause very little damage and the blood brain barrier prevents the leak of any enzymes into the general circulation. Now they have found a genetic test to find who

41 8

EMERGENCY MEDICINE UPDATE

has increased risk but no genetic test is cheap (Neuro 77(19)1716 ) I think since we measure troponin in nanograms per deciliter, it would make sense that at some point we will have sensitive assays, but we aren't there yet. TAKE HOME MESSAGE: No good marker for TIA exists yetbut a genetic one may exist. Let's go back to Hawkeye for a moment "This is the first case of teenage male menopause" or A device has yet to be invented that will measure my indifference to that remark" Speaking of indifference let's get Humphrey Bogart into the picture as well- this is from Casablanca: Lazlo" You detest me, Rick, don't you?" Rick (Bogart)" If I gave you any thought, I probably would" . Cool! 10) I do not know why so much urology crept in this month. Urethral trauma- this study was dreadful and was featured in a dreadful journal called Injury (42(9)913 )(Jerry calls this the European equivalent to the Journal of Trauma- another minus impact journal) But here are some interesting takes from it- remember the signs they all taught us in ATLS about when to think about urethral tear? Of course you remember: blood at the meatus well that is only 37% sensitive. Perineal hematoma is 44% sensitive. High riding prostate (I am not sure what that really is- I don not know that I have ever seen one (then again where would my head be if I had seen one?). All together41 9

EMERGENCY MEDICINE UPDATE

you get to 64% sensitivity which means we would miss a lot of urethral trauma which means we are inserting catheter into all sorts of people and may make incomplete tears into full tears. So what works? Well if you take all these together and add pelvic symphisis disruption you get to 100% sensitivity. However, alone this last sign is worth 92.5% sensitivity so adding all the other signs didn't help much. Now to get to 100% sensitivity you know that the specificity will be low but either one is rather silly to talk about here- what was the gold standard in their study? How did they know they didn't miss more? OK, I will leave them alone but they do make one more important point- we do not do many retrocystourethrograms and maybe we should do more, but ultrasound may be a good replacementmaybe. Lastly, if you are Gil Shlamovitz- and you probably aren't because there is one person I know who calls himself Gil Shlamovitz- then you will point out that if you catheterize an incomplete urethral tear blindly- it doesn't cause a complete tear.(J Trauma 62(2007)330 ) TAKE HOME MESSAGE: ATLS criteria for urethral trauma won't help you much- Ultrasound may help. 11) Here some more Urology for you, but we have spoken about it before. We reported a few months ago about the use of NCCT for renal stones has not changed the rate of urolithiasis diagnosis. This was based on a study form AEM
41 01

EMERGENCY MEDICINE UPDATE

(18(7)699 ). We just use the modality more, it really hasn't helped. Now the urologists did their own study and found the exact same thing (J Urology 186(6)2270 ). We just use the modality more, it really hasn't helped change much. TAKE HOME MESSAGE: CT should not be a routine part of your diagnosis work up for renal colic. In a related news flash: if you really want to get stoned, then pregnancy is the time to do it- in this tiny study they found that only half the time do pregnant patients manage to pass their stones without interventions- some managed to make it to after pregnancy to do interventions, some didn't- about 25% in both groups. Obviously a lot of bias here because again we do not know how many they missed (after all they didn't send a lot to CT so unknown how many really had this- didn't I just say something about that?) but keep this in mind especially in a known stone former (ibid p2280). TAKE HOME MESSAGE: Be more carful in pregnant patients their stones may stay stuck. I am really not sure why, but this seems to be a good place to say hi to Adam Singer; our good friend and publishing wiz at STONEYbrook. Lastly, how is this for a myth buster?- what can be holier than the use of antibiotics in uncomplicated urinary tract infections in young females? Give ibuprofen and after four days both those who got antibiotics and those who took

41 11

EMERGENCY MEDICINE UPDATE

ibuprofen (ibid 2152) TAKE HOME MESSAGE: UTIs may resolve on their own. 12) This article was an opinion piece and deals with post partum hemorrhage in financially strapped areas. The usual treatment oxytocin is pricey and needs refrigeration. Articles from Burkina Faso (you all know where that is- no, it isn't near Flint Michigan- the place where Greg Henry takes his vacations). (Very good, Ken, it used to be called Upper Volta), Vietnam and Pakistan have shown giving misoprostol in pill form can work and works well to stop the bleeding. (Int Journal Gyn 114(3)209 ). No real good science here, but if you have a situation where you need to control post partum bleeding and have nothing else try it. TAKE HOME MESSAGE: Cytotec can be used for post partum bleeding. 13) Giving paracetamol with ibuprofen to lower fever has no real dangers, but then again- no actual benefits. The authors point out why do polypharmacy to treat an entity (fever) that doesnt need treatment (Arch Dis Child 95(12)1175 ). TAKE HOMEMESSAGE: No need to combine paracetamol with ibuprofen for fever. No need to use either of them alone either. Now let me get this straight- a urology article is followed by a GYN article and then by a kid's article- is this responsible for the proliferation of medical literature? " Its Frank's birthday I wonder how old
41 21

EMERGENCY MEDICINE UPDATE

he is. Let's cut him in half and count his rings" "Frank can I borrow your doctor's diploma? We're a little short in the latrine" . Hawkeye strikes again. 14) Well, do we believe in complementary medicine or not? This study says you do. Actually health care workers are much more likely to use alternative medicine in this sample of 1280 with 14000 non health care workers as a control group. (Health Serv Res 47(1) 211) This doesn't help us that much because I am not sure how many of these were physicians. Many docs I know do prescribe alternative therapies but do they practice what they preach? TAKE HOME MESSAGE: We in the health field do actually use a lot of alternative and complementary therapies. 15) I am not really sure what to do with this study out of the Technion in Israel. Transient AF does happen after MI. Do you use anticoagulants if it is transient? Seems these folks have a higher rate of TIA and stroke so they recommend doing it. (Thromb Haemo 106(5)877 ) However, these patients may have worse MIs and as such have more of a preponderance of CVA even without the Afib. I would also be interested in knowing if you treat transient Afib in the ED with anticoagulation. I generally just recommend a Holter and have the family doc use that to make my decision. TAKE HOME MESSAGE: Transient AF after an MI can portend to future TIA/CVAs.
41 31

EMERGENCY MEDICINE UPDATE

Another opinion piece- but this goes into the "don't be an idiot department". With so many good therapies for migraines-why opioids are the first go to drug for many physicians is bewildering. Also-just like with kidney stonesimaging is way overused. I save it for thunderclap headaches, people with cancer or AIDs or taking Coumadin, and in people with neuro findings. I do not agree with the author's contention that a headache diagnosis is always possible- I think there is much overlap even in definitions. (Headache 51(8)1276).TAKE HOME POINT: Headaches should not receive opioids and imaging is not necessary in most cases. 17) Intravenous lidocaine for the treatment of pain, specifically in burns doesn't work. Not that I really expected it would. (Burns 37(6)951 ) If that isn't convincing enough, Cochrane also says this (June 2012 CD 005622 ). TAKE HOME MESSAGE: IV lidocaine is not a pain treatment option. Now let's hear from Col Potter "You have to give Winchester credit. He is bright, educated and an A-1 surgeon and with all that he still found room to be a total jerk" . And while we are speaking about Winchester, here is a comment of his " Ah, Corporal Klinger, my constant reminder that Darwin was right" . 18) Now related to above- NCCT in kids with stones also doesn't give you much over an ultrasound in kids (Urology
16)
41 41

EMERGENCY MEDICINE UPDATE

78(3)662 ). This would greatly reduce the radiation exposure to kiddies. True this was a tiny study and again we do not know how many were missed, but the point is well taken. TAKE HOME MESSAGE: Avoid CTs in kids with kidney stones. They also don t help. Now we have Urology article let's take the proper precautions to avoid another peds article

There is an assay to determine a person's tetanus status and this would save us some much in those patients that do not know their status. This Iranian study was problematic however. (AJEM 29(7)721). Firstly, this does not take into account an amnesic response. Secondly the cost of an immunization is so cheap and the side effects of an unnecessary immunization is so low, it probably doesnt justify doing the test. And of course, we do not know who paid for the study. TAKE HOME MESSAGE:
19)
41 51

EMERGENCY MEDICINE UPDATE

Tetanus immunization status can be determined by a point of care test. 20) Nor epinephrine is very hot these days for shock, and indeed- this old drug that was always known as a kidney killer in this study was shown to actually protect the kidneys in this Chinese study (ibid p731). However, this was done by measuring surrogate markers. And was done in pigs. TAKE HOME MESSAGE. If you are a pig, your kidneys do much better in shock with nor epi. If you aren't a pig, then we will need more info. And if you aren't sure what you are.. I tell you I get no respect. Once I was travelling with a Jew and Hindu and we got stuck. A farmer agreed to put us up, but he only had room for two in the house; one had to sleep in the barn. The Jew agreed, but a few minutes later there was a knock on the door and it's the Jew- I can't sleep in the barn- there is a pig there. The Hindu agrees to go out to the barn, and a few minutes later there is a knock on the door" I can't sleep there, there is a cow in the barn" He says. So I agreed to sleep there and few minutes later there is a knock on the door. It was the cow and the pig" 21) Here's an article from USC- LAC- while Kenji Inaba is an author and is a great speaker and a great surgeon, I do not know him personally, but I do know Stu Swadron so I will give him a shout from here. Stu is an EMU reader now
41 61

EMERGENCY MEDICINE UPDATE

for about 7 years. We have been warned never to give pressors in trauma. And in this study- , vasopressors did cause more mortality (J Trauma 71(3)565 ). However, I have a lot of problems with this study. It is retrospective, and we can't know why the people who got pressors actually got them- were they sicker? Now true the ISS were not correlated with mortality if they got pressors (so can't perhaps say the sicker ones were the ones that got pressors) but you still have to know why they were given them. And somehow- those getting vasopressors with hypovolemia didn't do worse, while those without hypovolemia did do worse if they got pressors. I can't really explain that. On one side, I do not think we should be so restrictive in trauma to exclude pressors completelythey may have a role, we just do not know what and which pressors. On the other side- pressors do not save lives in any patients. Here is Dr. Shlamovitzs take- he has published extensively on trauma: Reviewers comment (Gil Shlamovitz): While no evidence to support this practice it has been my experience that some blunt trauma patients go into a PEA state as a result of spinal shock that sometimes is not that apparent especially if the patient has low GCS. While anecdotal, IV epinephrine followed by pressors were able to restore peripheral pulses and BP to allow further workup and survival. Not always easy to identify those patients but a good place to start is no BP and HR lower than what one would have
41 71

EMERGENCY MEDICINE UPDATE

expected, no blood in the chest or pericardium (US +/- chest tubes), no blood in the belly (US), YES blood in the big vessels (Vena Cava and RV by US). While some of those patients might have retroperitoneal bleeds or minimal fluid in the belly, IV fluids, blood products and sometimes a #10 blade for an exlap will be indicated before they can safely unergo a CT +/- an MRI to make the final diagnosis. Thanks Gil- very good tip! TAKE HOME MESSAGE: Pressors may worsen mortality in trauma. Or maybe not. "Let's shoot him and put him out of our misery" Hawkeye. " Seeing the way you guys work with the wounded, the way you deal with burned up legs, ripped up bellies. Makes me proud every time I throw up" How's that for an evaluation of trauma? Comes from Corporal Klinger. 22) Swollen leg, fever- is it a DVT or cellulitis? Don't hang your hat on the latter. DVT can present with fever and they do worse actually.(J Thromb Thromb 32(3)288 ) Now this article did not factor in the classic signs of cellulitis which include redness and pain but these can be present in DVT as well. Have a low threshold for doing a Doppler study. TAKE HOME MESSAGE: Fever can be present in a DVT. However before you take this home with you see number 31 below. 23) Depends who you believe. If you are an Iranian kid, well then zinc will reduce your fever faster, and get you discharged faster if you have a severe pneumonia and you
41 81

EMERGENCY MEDICINE UPDATE

take it as adjuvant therapy. The children were randomized. (Ind J Peds 78(9)1079) If you were an Indian kid, it didn't work (ibid 1085). If you were from Nepal (OK, it is isn't near Burkina Faso, but it has Mount Everest in it and it borders India) (and by the way, it's capital is Katmandu which was the title of a song sung by what 1970's singer?) It worked marginally.(Peds 129(4)701). And if you are from Harvard and write Cochrane reviews it doesn't work (Cochrane CD007368 ).Doesn't seem too encouraging. I couldn't tell from the statistics why there is one good study. TAKE HOME MESSAGE: Forget zinc for pneumonia. Now to help you a little with this question the singer of

Katmandu looked like this

41 91

EMERGENCY MEDICINE UPDATE

Now not really a great question in 23- since also Bob Seeger wrote a song with the same name in 1975. The picture above is Cat Stevens, presently known as Yusuf
24)

Islam. And there is no truth the rumor that his real name was Steven Katz and that he was Jewish, Actually his real name was Steven Georgiu and he was actually Greek (although he lived in England). 25) Yawn- case reports. But I want to use this as a reminder for the "if all else fails, pull this chain"

41 02

EMERGENCY MEDICINE UPDATE

. Lipid emulsion has been used for local anesthetic toxicity, lipid soluble drugs (such as lamotrigine) and also calcium channel blockers, beta blockers and anti depressants- all ferocious overdoses. Since cocaine is both an anesthetic and lipid soluble they tried it on an unstable drug overdose and it worked wonders. (Anaesthesia 66(12)1168 ). Just keep this in mind I think we are still evolving as to where and how we can use this stuff. TAKE HOME MESSAGE: Lipid emulsion may help for cocaine overdose. 26) This idea has been thrown around and they want to say that empathy as perceived by the patient results in improvement in colds in patients that have them- and ergo may help other conditions (Pat Ed Counsel 85(3)390 ). They measured disease oriented outcomes- interleukin levels which doesn't help us much but they also studied severity and duration - which are patient oriented outcomes- and

41 12

EMERGENCY MEDICINE UPDATE

they were better. However, severity was also measured by surrogate markers. Duration was reduced by a little more than a day. Note there is a problem how you quantify empathy- true they use a score called a CARE score but I do not now if it has been validated. Moreover- this was a randomized study- what does that mean- that half the patients they were mean to and half nice to? BTW this was studied before by the same authors- not good. (Fam Prac41(7)414). TAKE HOME MESSAGE: be nice and your patients will get better faster. 27) Would you like ice with your cardiac arrest? If this question sends shivers up your spine, then we need to treat you. That the answer to the first question is yes is pretty clear from a number of studies (see JACC 60(1)21). The second statement is a little trickier- -shivering is very uncomfortable and does not allow for maintaining core body temperature. Meperidine remains your first choice, with the new dexmedetomidine, midazolam, fenatyl and magnesium sulfate as secondary agents. (Crit Care Nur 31(6)e18 ) Actually not the first article on the subject- the review in Pharmacotherapy 30(8)830 is more extensive, but the same problem remains- evidence in any case isn't great. Poor Hot Lips Houlihan was the target of many of Hawkeye's barbs "Hi good looking, get sick here often?" Colonel Potter had to once say: You blow another kiss, Hawkeye, and those
41 22

EMERGENCY MEDICINE UPDATE

lips will never walk again" and Potter on Corporal Klinger "I've got a soft spot for Klinger. He looks like my son and dresses like my wife" . 28) Time for another clinical quiz which may have some relevance to some one, but I am not sure who. OK, this 49 year old guy has a headache. In the ED, he has a 200/114 blood pressure. Now how many out there want to lower his BP and send him packing? I am not saying that isn't appropriate in some cases, but you gotta remember the big 4 for blood pressure urgencies- dissection, CHF, stroke, renal failure. Now most of these are pretty obvious on a good history other than renal failure. So let's take some blood tests. Now everything comes back normal. Well almost normal- the Potassium is 2.2. Now what? Give them some KCL and send him packing?? Well, if you decided to admit him you would have found low renin and aldosterone levels. Now what? OK, guys, don't jump all over me, I know there isn't enough info so I will help you- this is an overdose- but of what??( QJM (12)1093 ). Now I got a lot of IM readers including some from IM B at Meir hospital and IM E at Tel Hashomer- so you guys for sure know the answer. And if you don't the punishment is I'll continue your subscription to EMU.

41 32

EMERGENCY MEDICINE UPDATE

So while you are being a genius- what is this? Hint: it isn't blistering dactylitis. But you knew that. Just don't open it and don't give antibiotics. (Ind Ped 48(8)665 ) By the way we have one reader from India and I wanted to say that this journal has been quoted often in these pages because it really is a good journal. Try it out sometime. 30) If you really do not know how to handle fingertip and nail bed injuries then this basic article may be a good one to read, but we will highlight some points that were perhaps less obvious. Subungal hematomas I thought- do not need exploration. They say it is controversial. I think there really is no reason to do so. Using glue if you do want to close a laceration on the nail bed seems like a better idea then attempting suture repair- the skin is very friable in the nail bed. Fingertip lacerations- re attach the
29)
41 42

EMERGENCY MEDICINE UPDATE

tip even if it is not viable (but not if it is dirty). This will be a biological dressing until it falls off. BJHM 72(8)M114 ). TAKE HOME MESSAGE: Nail bed and fingertip injuries are really no challenge- you should be able to handle them. 31) This could have been an essay but this is already a long issue- is anyone really reading at this point? It is also a boring subject. Cellulitis- think you already know every thing? You probably do, but I didn't. Would you believe that at this point that most Staph Aureus skin infections are MRSA? So as such, identifying staph infections is even more important. What seems- and it is a big seems - is still true that if the cellulitis weeps or has a purulent dischargeit is probably staph. If it is raised and clearly demarcated then it is most probably strep. Abscesses just need opening please, just please stop using antibiotics and culturing them. (we will not speak about necrotizing infections at this point). DVT can be confused with cellulitis but this is not as common as we think- in one study they found none, in another they found 17% incidence. Also herpetic whitlow can be confused with this. Rarer stuff that looks like this are Sweet's syndrome, FMF, and Pyoderma Gangrenosum. The IDSA is still speaking about blood cultures and needle aspirates but they agree that they are optional and I think they are a total waste of time. Antibiotics: depend now if you are covering MRSA or just
41 52

EMERGENCY MEDICINE UPDATE

strep and remember TMP SMZ does not cover strep well. But the surprise is that five days of therapy is probably enough. My experience is that these are stubborn infections but this is what they write. They also recommend steroids but as we know that is the cure for everything. (AJM 124:1113) I would like to add that ultrasound is a great idea here if you aren't sure about fluctuance. Or flatulence. TAKE HOME MESSAGE: Cellulitis nowadays is either MRSA or Strep- and the difference is usually based on clinical grounds. 32) I am sure no one is reading at this point. But now I am going to get personal. If you are still reading then drop me a line about your ideas here. In the past we presented an Australian article about aging primary care docs who were getting dangerous due to aging issues. This Annals of EM article (58(3)15a ) takes a bit of a different viewpoint. Airline pilots have periodical checks of their competence and mandatory retirement. We know in medicine the older you get the worse your outcomes (the problem here is that this research was done on all physicians-neurosurgeons could be very different than pathologists). CME and recertification seem to make no difference. Now that CME makes no difference is understandable since the quality of CME is very variable and has never been shown to alter outcomes; but I feel
41 62

EMERGENCY MEDICINE UPDATE

that CME is necessary especially when docs have no exposure to academic medicine (of course if you read EMU you do not have this problem). In Israel there is no recertification unlike the USA which does and also the USA has LLSE- mandatory tests on the literature. Returning to the article: they surveyed ACEP members and found that the older you get the harder it is to recover from a night shift- no surprise here and considerable percentages of physicians found more difficulty in handling heavy patients loads, the overall stress of emergency medicine and incorporating new modalities in their practice. Many centers actually have exempted older docs from night shifts. The Israeli system has no night shifts for attendings but I must admit that evening shifts and hard shocky patients do physically exhaust me. Exempting older docs and shorter shift work would involve greater outlays of money to hire more docs, so older docs- despite having a lot to contribute to the next generation often find themselves pushed to the side- a feeling I have definitely felt. And indeed, this month- for the first time in 26 years- I have cut down my EM practice to the point that I no longer work full time in EM. And I know that my ultrasound skills are no where near those of the new guys. And I know I just can't get excited as I once did with the chest pains and the dizziness and the fevers in nursing home patients with contractures. But I
41 72

EMERGENCY MEDICINE UPDATE

have experience and basics that allow me to intubate without the video laryngoscopes, and hands that have never missed a CVP and a brain that can somehow say this is a heart problem and not a gall bladder (and vice versa) without being befuddled. I rarely during the course of a day have to check a palm, ipod , MEDSCAPE or the like. And I still get the rush when we pull a CHFer out of trouble or put back a shoulder. I have 14 years of running an ED. However I understand that a program would be more interested in a younger fellow who could do the extra hours and has the technological training. But mandatory retirement? Fine for the pilots- that have a great pension, but most of us do not. This doesn't interest you too much? Well just remember one day you will be where I am. Don't say I didn't warn you. (Just want to point out the EMU reader Al Sachetti was a contributor to this article. Al- if you are still reading- let us know what more you have to say) TAKE HOME POINT: EM has to provide a framework for the aging physician. And that is you. 33) Last article is from Eli Schwartz- a really nice guy and the expert in travel diseases- speaks about two zoonoses that you gotta know about. The first is the most common zoonosis in the world. It is spread through the urine of animals (no you can't get it from using the bathrooms at Yankee Stadium) and think of it if the patient in your ED or
41 82

EMERGENCY MEDICINE UPDATE

clinic returns from South East Asia and has fever, hepatitis, jaundice, myocarditis or encephalitis. I knew about the liver failure but didn't know that a pulmonary form exists with high mortality. There is no real good way to diagnose this quickly and Doxy taken prophylactically will not help. Oh, I will stop beating around the bush- this is Aerophilous. Oh, you know already not to believe me. S why you are scratching your head (we will speak about lice another time)- this is really leptospirosis. And this time you can trust me. He also speaks about rickettsia- as with RMSF where you do not need to have a rash, nor be from the Rocky Mountains or even have a fever. If you have a fever, rash and an eschar- think of the rickettisial diseases even though you don't need to have all of these. Muarine Typhus, Scrub Typhus- you aren't going to make these diagnosis from the ED, but keep it in mind if you see these three findings. ( Cuur Opinion Inf Disease 24:457 ) Personally if it is a fever and a rash I think of rickettsia. Or punt. 34) Answers to questions- number 6 above were colchicine induced neutropenia which resolved nicely after the colchicine was stopped. And number 29 was herpetic whitlow which we referred to above. And for our internal medicine eggheads- number 28. That patient took a little too much licorice in his daily repasts. I'll say hello to those
41 92

EMERGENCY MEDICINE UPDATE

IM guys- Hi Alon and Prof Schneider. Alon previewed the clinical quiz and nailed it immediately. Smart guy, a shame he isn't in emergency medicine 35) And now for letters. Rick Bukata- yes the Rick Bukata from Emergency Medicine Abstracts comments on the article we mentioned last month on the subject of vertigo Here is what he has to say: I downplay the diagnosis of PBPV in the ED because my
readings say it only lasts 10-40 seconds and as such, would be over before someone presented to the ED. The diagnosis that we are dealing with is, I believe, vestibular neuronitis -- persisting positional vertigo that can

If I may add my thoughts- it is true we see a lot of vestibular neuronitis in the ED, and many of us have not found re positioning maneuvers to help much in the ED and end up admitting a lot of these patients. But I do believe recurrent BPPV does occur just like biliary colic and do succeed in sending some of these folks home. Thanks Rick for writing. And yes-if you do not yet know who Rick is-go up to the CCME website and get a hold of his monthly programs. If you are a primary care doc- he has audio programs for you too. 36) And Dr. Simcha sends us a listing of articles that recommend vitamin and mineral therapy for many serious conditions. The letter is too long to print but here are some of the articles: Vitamin B 12 given parentally can blunt the response to sepsis (this article checked surrogate markers of inflammation and sepsis), Vitamin C given IV once at the start of sepsis can attenuate the sepsis (also same problem of surrogate markers). Ditto for melatonin in
result in a person begin hospitalized for symptom control. Cause is really unknown.

41 03

EMERGENCY MEDICINE UPDATE

septic infants and the use of nicotine in sepsis. IV selenium did include mortality data but it was not controlled. But instead of me dissecting the data , no one compares with Dr. Scott Weingart- and EMU Subscriber and an ICU/EM guru- who states succinctly but what a pearl: all of these may pan out,
but none are ready for prime time. Large scale, well performed trials have an unfortunate tendency to destroy promising new therapies like this. And of course we must always remember that doctors have a name for natural supplements that work: medications

Scott and Simcha- thanks for writing, and Scott if you are still reading let me quote HL Mencken for you as you do practice in New York: Every great wave of popular passion that rolls up on the prairies is dashed to
spray when it strikes the hard rocks of Manhattan. H. L. Mencken

And a warm Hello to Dr. Y , our cardiology consultant (unfortunately efforts to get Amal Mattu to subscribe to EMU have not been successful but we are still trying) whose comment on last months' article about ST elevation with Q waves- I commented that they also do not know when it is real and when it is an aneurysm. His comment was **&%$#@+)~@@!

41 13

EMERGENCY MEDICINE UPDATE

37)

Here are the guests of our EMU: Hawkeye Pierce-

played by Alan Alda

Winchester

played by David Steirs, Frank Burns

played by Larry Linville

, Radar O'Reilly played

41 23

EMERGENCY MEDICINE UPDATE

by Gary Burghoff,

Colonel Potter played by

Harry Morgan

, Trapper John played by

Wayne Rodgers

Klinger played by Jamie

41 33

EMERGENCY MEDICINE UPDATE

Farr,

and Margaret Houlihan played by

Loretta Swit.

EMU LOOKS AT: EARs and hEARts

This month we in honor of all our articles above from the uro literature- we will dedicate our articles this month to kids. However before you close the computer- these are diseases we could see in adults as well- you just missed them or didn't care. Our sources for the essays are J Paed Child Health 45:554 and Pediatric Rheumatology 9:17 2011
41 43

EMERGENCY MEDICINE UPDATE

1) OK smart alack, we are going to toughen you up on otitis media.

This article had a real bent towards Australian indigenous children and I am not sure how that applies to the rest of the world (apparently there is a difference between indigenous and not indigenous children in Australia) but aside from that caveat- a well done article. Otitis media is defined as a spectrum of three separate entities. Acute otitis media, otitis media with effusion and chronic suppurative otitis media. And if you understand that that is quite an accomplishment. In a recent survey of 165 clinicians they got 147 different clinical definitions of AOM, with no definition agreed on by more than six clinicians. So this says: if you just say I do not know what this so I'll just slide them over to an ENT- you're are an idiot and he probably is one too, being that he is probably one of the 165 clinicians. Let's use their definitions. AOM requires acute onset- less than 48 hours; fever, and middle ear fluid bulges or absent movement of the tympanic membrane (you need a pneumatic otoscopy) and redness. Think about the last time you diagnosed AOM and tell me if you had all three of these criteria. Effusion is shows signs of fluids. Chronic suppurative OM shows pus though a perforated tympanic membrane- but this is a persistent problem and usually isn't called CSOM unless two weeks have passed. 2) Who is at risk for OM? Cleft palates, day care, tobacco smoke, pacifier use, and breast feeding and lack of breast feeding. Confused? All of these "risks" are modest. And what they meant with breastfeeding is that breast fed but not for a long time or not
41 53

EMERGENCY MEDICINE UPDATE

at all is a risk. However a look at the relative risks finds that highest risk- and the best p value- was family history- which is my experience too. 3) Diagnostic aids- pneumatic otoscopy is cheap and easy. If has good sensitivity and fair specificity. Tympanometry is like an ultrasound of the ear. It has good sensitivity but poor specificity. Curiously, this fancy equipment test is no better than the otoscopy. Tympanometry cannot be done in the presence of a discharge from the ear drum. 4) Treatment. Watchful waiting is now acceptable. Multiple studies have shown a minimal benefit from antibiotics which may not negate the side effects. Mastoiditis rates do not increase in kids who were given this approach. Otorrhea and kids under two show the greatest benefit of antibiotic use 5) Effusion- what have I not seen used for this? I have seen diuretics, I have seen multiple courses of antibiotics, I have seen decongestants, I have seen enemas (works only for those whose ears are in that vicinity). The truth is that most will clear spontaneously after three months no matter you do or don't do. Oral antibiotics are often used after three months, but with minimal results. Steroids- they work for everything. Antihistamines and decongestants have a higher number needed to harm than to treat. They recommend a hearing test, and if it is affecting hearing- put in tubes (no not a rectal tube- I was joking above). This is all after three months. CSOM- use ear cleaning either by irrigation or dry cleaning with a cotton tip applicator ( I was always taught not to
41 63

EMERGENCY MEDICINE UPDATE

recommend this) and use antibiotic drops. Here is an important take home point- this condition is much more common than otitis externa in kids. If you have an otitis externa that is not resolvingconsider this- and check for a perforation where antibiotics may help. I can't explain my twisted mind, but since I have a soft a spot for Brits (Hi Angie), I will quote Winston Churchill, who was famous for his bickering with Lady Astor, an American and the first woman to be seated in the House of Commons (his comment when she was appointed was " I felt as if she had come into my bathroom and all I was left with was a sponge to defend myself". She was famous for her wit, once saying "I married below me- all women do". Well they once were verbally sparring at a weekend retreat and she stated "Winston, if I was your wife, I would put poison in your coffee" He quipped" If I was you husband, I would drink it"

41 73

EMERGENCY MEDICINE UPDATE

The second essay is on Kawasaki Syndrome. You never saw this? Well since there is no diagnostic test for this, you probably have seen it and missed it. So you shouldn't miss it again, here it is:

And in case you are afraid you might confuse it with another entity here is the most confusing similar condition

41 83

EMERGENCY MEDICINE UPDATE

So let's get started. This is as you know a necrotizing vasculitis, more commonly found in males and mostly seen in kids from about half a year until 5 years old. Peak incidence of this disease is in less than one year in Japan where they see most of the cases. In the USA they see most cases in the less than two year old age group. As I said above you will not make this diagnosis on a blood test- you need a prolonged fever (five days) and a rash, conjunctival injection, oral changes (lip fissuring, strawberry tongue, hyperemia) and cervical lymphadenopathy which is the least seen. 2) The current thought is that an RNA virus causes this, but it is far from clear. 3) Yes there is an atypical Kawasaki. This has fever and signs such as abdominal pain, pleural effusion, neck stiffness uveitis or a number of other signs that basically could look like anything. In addition there is incomplete Kawasaki which has fever, 2 of the clinical criteria and coronary artery aneurysms on echo. So what can help you make the diagnosis in these two variants? CRP and ESR can be much higher on day four or five of the illness than other viral entities. They tend to be more irritable than other kids. And if they had BCG in the past they may have induration at the inoculation site. So you say- my patients are all irritable, and none have BCG inoculations. So that doesn't help. Furthermore, Idiopathic juvenile onset arthritis can look exactly like this with the same lab findings. So what happens if you miss the diagnosis? Well, if they develop coronary artery aneurisms- you
1)
41 93

EMERGENCY MEDICINE UPDATE

are in deep trouble. As Greg Henry would say (that was a picture of his Harley above) you will get a new name- not the attending doctor but the defendant physician. Basically I get worried about kids with a prolonged fever and admit them. As Leibman says any fever over five days has to be bad. 4) IVIG is the therapy- use 2 gm/kg in a ten to twelve hour infusion, and give aspirin 50-100 mg/kg) Clopidogrel is used in aspirin allergies. 5) Steroids may help (they help for everything) but this has been shown in only one study. 6) If that doesn't work, Infliximab and Etanercept- both TNF blockers have help in small studies, 7) . If you blew it, than these patients with aneurysms will need life long anticoagulation. How to handle these patients and what activity, and testing should be done in the long term can be seen on the chart in this article. Vaccinations should be given but at least nine months after the last IVIG. 8) If there is a doubt- echo! I'll like to take this opportunity to apologize to Greg Henry who I was a little hard on this month. I do like him and respect him and

41 04

EMERGENCY MEDICINE UPDATE

so I dedicate this picture to him: (and yes- Greg stills wears the suit jacket that this fellow is wearing) 9) And lastly one last M*A*S*H quote Frank: I am a great doctor- just ask any of my patients. Trapper John: Frank, We cant dig people up just for that.

41 14