PAPER REVIEW
| ARTICLES THAT HAVE CHANGED MY PRACTICE —Christian Tomaszewski, MD, Associate Professor of Emergency
Medicine, Carolinas Medical Center University, Charlotte, NC
|
| Oligoanalgesia: too little pain medicine; physicians accused of not giving enough medicine to, eg, children, certain ethnic
groups; study—looked at whether morphine 0.1 mg/kg adequate starting dose for pain treatment; morphine comes
in 4-mg and 10-mg ampules; morphine prototypical analgesic; inexpensive, few drug interactions, and has wide range
of dosages; traditional starting dose 0.05 mg/kg; studies show 10 mg subcutaneously gave relief in 66% of cases; purpose
of study to determine who had >50% reduction in pain after receiving 0.1 mg/kg of intravenous (IV) morphine;
prospective cohort study of patients 21 to 65 yr of age; visual analogue scale (VAS) used immediately before giving
morphine and 30 min after; diagnosis mostly abdominal pain; mean pain score 10; women comprised 55% and Hispanics
65%; results show 67% of patients reported >50% decrease in pain; no patient required opioid antagonist; incidence
of vomiting <1%; conclusion—0.1-mg/kg dose of morphine too low to control severe pain
|
| Reducing nursemaid’s elbow: literature recommends starting with supination; if ineffective, perform pronation; study
compared perceived pain during 2 procedures (forced pronation and supination-flexion); pronation simpler; parents
and nursing staff perceived forced pronation as less painful; other studies also support pronation
|
| Dose of succinylcholine in morbid obesity: succinylcholine has rapid onset and short duration; appropriate dose in
obese patients unknown; study—45 morbidly obese patients, with body mass index (BMI) >40 kg/m2 and otherwise
healthy; intubation sequence included fentanyl, propofol, midazolam, and oxygenation with face mask; randomized to
succinylcholine dose of 1 mg/kg of ideal body weight, 1 mg/kg of lean body weight, or 1 mg/kg of total body weight;
rated ease of intubation (excellent, good, or poor); poor defined as no relaxation of jaw and active resistance; excellent
defined as relaxed jaw with no resistance; results showed that basing dose on total body weight provided good-to-excellent
intubation; more succinylcholine results in longer time for twitch to return; other studies support 1.5- to 2-mg/
kg range; higher dose increases duration of action; conclusion—dose of succinylcholine should be based on actual
body weight
|
| Fever: leads to parental anxiety; study—compared antipyretic benefit of acetaminophen or ibuprofen monotherapy to
alternating regimen of both; surveys show 50% of parents give both (alternating); children 6 to 36 mo of age with rectal
temperature of 101°F (38.4°C); randomized to acetaminophen 12.5 mg/kg q6h, ibuprofen 5 mg/kg q8h, or alternating
acetaminophen and ibuprofen q4h; results showed fever reduction faster with alternating combination, with no
difference between acetaminophen and ibuprofen groups; those in combination group received less total medication
than other 2 groups; fewer daycare absences in combination group; emergency department (ED) revisits, although
fewer in combination group, not significantly different; study—70 febrile children received ibuprofen 10 mg/kg initially;
randomized at 4 hr to acetaminophen 15 mg/kg or placebo; result showed addition of acetaminophen early to
ibuprofen facilitates reduction of fever
|
| Minor head injury: study—comparison of Canadian head computed tomography (CT) rule and New Orleans criteria
in patients with minor head injury; both do not use loss of consciousness (LOC) as criterion for obtaining CT; New
Orleans criteria require CT, even with minor head injury, if Glasgow Coma Scale (GCS) score 15 and patient has any
of following, headache, vomiting, age >60 yr, drug or alcohol intoxication, persistent anterograde amnesia, visible
trauma above clavicles, or seizure; Canadian head CT rule requires CT if GCS score <15 at 2 hr after injury, suspected
open or depressed skull fracture, any sign of basal skull fracture, >2 episodes of vomiting, and age >65 yr; signs of
basal skull fracture include “raccoon” eyes, cerebrospinal fluid rhinorrhea or otorrhea, and hemotympanum; should
not have medium-risk criteria (amnesia >30 min and dangerous mechanism of injury); dangerous mechanism includes
pedestrian struck by motor vehicle, occupant ejected from motor vehicle, and fall from height >3 ft; prospective cohort
study—cohort age >16 yr; 9 Canadian tertiary hospitals involved; convenience sample with minor head injury
and GCS score of 15; eligibility criteria included blunt head trauma with witnessed LOC, or definite amnesia for
event, or witnessed disorientation, ED GCS of 15, and injury within 24 hr; injury defined as finding on CT requiring
hospital admission and neurosurgical follow-up or requiring intervention within next 7 days; both had 100% sensitivity
for clinically important brain injury and neurosurgical intervention, but Canadian rule had better specificity, thus
reducing imaging rates
|
| REVIEW OF RECENT EMERGENCY MEDICINE LITERATURE —Diane M. Birnbaumer, MD, Professor of Clinical
Medicine, David Geffen School of Medicine at the University of California, Los Angeles, and Associate Program Director,
Department of Emergency Medicine, Harbor-UCLA Medical Center, Los Angeles
|
| Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA): Moran et al (2006)—422 adult
patients in 11 university-affiliated hospitals; demographic and microbiologic profile of subjects; cultures and clinical
information collected; nationwide, 15% to 74% of skin infections MRSA; looked at antibiotic susceptibility and found
trimethoprim-sulfamethoxazole (TMP-SMZ; Bactrim) effective; also rifampicin and clindamycin (95% effective);
fluoroquinolones 60% effective; erythromycin ineffective; concluded that majority of skin infections in United States
MRSA; in 57% of patients, first antibiotic prescribed ineffective (usually β-lactam); overview—younger previously
healthy people affected; first diagnosed in athletes, prisoners, and military trainees; recently reported in healthy newborns
(pustular diaper rash) and tattoo recipients; for most part, presents as skin and soft tissue infections; one clue abscess,
usually relatively small, especially if multiple; 20% cultured from nose; treatment—different from hospital-
acquired MRSA; does not respond to β-lactam antibiotics; can have concurrent Streptococcus infection, so if gnarly
cellulitis present around abscess, add β-lactam to MRSA coverage; sensitivity pattern may include linezolid (extremely
expensive and should be reserved for severe infections; serotonin syndrome recently described in patients on
selective serotonin reuptake inhibitors [SSRIs] who took linezolid); sensitivity changing rapidly; must perform incision
and drainage and culture on all abscesses for surveillance (to determine how resistance patterns change); know local
risk for CA-MRSA; if in high-risk area, current recommendation to treat local infection and add rifampin
(eradicates nasal carriage state); alternative treatments—clindamycin; consider having patient wash head to toe with
4% chlorhexidine (Hibiclens); recommended primarily in families with multiple members infected or child with diaper
version; mupirocin (Bactroban) alternative to rifampin for nose; if hospital admission necessary, IV vancomycin
given (if infection not that severe, IV clindamycin; may be used in outpatients); morbidity—48 necrotizing fasciitis
cases in 15 mo, of which 14 from CA-MRSA; presented as indolent cellulitis, not as severely sick cases;
pneumonia—seen when influenza season severe (tends to attack lungs already damaged from recent viral infection);
raging and rapidly fatal infection; consider in presence of hemoptysis, shock, leukopenia, history of influenza, and
cavitary lesions on chest x-ray; prevention—hand washing for 30 sec; take-home message—if cutaneous abscesses
and pustular diaper rash seen, think CA-MRSA; culture all abscesses; know local resistance pattern and treat accordingly;
beware of more serious infections
|
| Syncope: Quinn et al (2006)—follow-up prospective cohort validation of San Francisco Syncope Rule; after history,
physical examination, and quick laboratory tests, 50% of time cause found; tried to determine which of remaining
50% would have poor outcomes; excluded people who were traumatized, used alcohol or drugs, or had seizures; according
to syncope rule, anybody with history of congestive heart failure, hematocrit <30%, abnormal electrocardiography
(ECG), complaint of shortness of breath, or systolic blood pressure <90 mm Hg at triage (mnemonic CHESS)
considered high risk for serious outcomes; 791 ED visits for syncope; average age 61 yr; 60% admitted to hospital;
13.7% had serious outcome at 30 days, of which 7% not apparent on initial ED evaluation; other 7% predicted by syncope
rule; 3 missed cases, with one case potentially fatal; overall sensitivity of rule 98% and specificity 56% ; if rule
applied to everybody, would decrease admission rates by 24%; not meant for application to all who presented with
syncope; meant for prospective application to subset of people in which cause of syncope unknown after initial evaluation;
still have significant potential for missing serious disease; needs larger study in multiple institutions; speaker
thinks rule not ready for general application
|
| Sepsis: study—looked at whether early goal-directed therapy to improve outcome in sepsis can be done in ED; goal-directed
therapy includes maintaining central venous pressure (CVP) >8 mm Hg (using vasopressors if necessary, with
goal of ≤65 mm Hg) and ensuring O2 delivery (with dobutamine or packed red blood cells) to get saturation >70%; all
but 2 obtained end points; most obtained goal of <6 hr; concluded that if performed aggressively in ED, mortality rate
decreased; Nguyen et al (2006)—retrospective case series of patients with severe sepsis; looked at CVP and O2 saturation
and whether started in ED; 24 patients; overall predicted mortality based on formula; all patients received antibiotics;
early goal-directed therapy not performed in 50% of patients; steroids used in 33% of patients and activated
protein C (APC) in 33% of patients; overall in-hospital mortality 25% (less than predicted); issue of what is feasible
and what is necessary; steroids—recommended for use in patients who need vasopressors (should be ordered at same
time as vasopressors); people who inadequately respond to adrenocorticotropic hormone (ACTH; cosyntropin [Cortrosyn])
stimulation test ones who benefit, but those who do not respond have worse outcome; APC—beneficial in
limited number of patients; can be given within 24 hr of initiating patient’s care and still obtain benefit (given by intensivist;
costly and not benign)
|
| Clostridium difficile–associated diarrhea: now associated with fluoroquinolones; also seen in patients not on antibiotics;
most concerning group peripartum patients (infection highly lethal; one third died); high rate of miscarriage; elderly
not clearing infection (recurrence rate 50%); characteristics of organism—spore-forming; ingestion of spore
can cause infection; spores very hardy; 2 exotoxins; from 1996 to 2003, hospitalization rates doubled; causes 7% of
diarrhea in children in ED; presentation— abdominal pain, diarrhea (may become bloody), fever (usually; 104°F);
with or without risk (antibiotic exposure); Quebec experience (Pepin et al 2005)—report of 293 confirmed cases;
mortality rate ≈6%; fluoroquinolones most strongly associated antibiotics; 33 cases had no risk factors; consider if diarrhea
>3 days, blood in stool (microscopic or gross), and fever present (send sample for C difficile toxins); patient not
chronically ill and has not been in health care facility for >3 mo; recommendation to minimize fluoroquinolone use;
note—problem in people on histamine-2 (H2 ) blockers or proton pump inhibitors (need stomach acid to destroy
spores if ingested); implicated in nursing home outbreaks; spores not killed by ethyl alcohol gel (30-sec hand washing
required)
|
| Vasopressin: review of studies comparing vasopressin to epinephrine for prehospital cardiac arrest; one study showed
vasopressin effective, even for asystole (not supported by further analysis of data); no evidence to confirm consistent
benefit of vasopressin over epinephrine
|
| Tamsulosin (Flomax) for kidney stones: one study compared Flomax to α agent and found that stone passed more
quickly in Flomax group; 2005 prospective randomized controlled trial (RCT) looked at distal stones 4 mm in size and
found that stones more likely to pass and passed sooner with Flomax; another prospective RCT compared Flomax with
usual therapy in patients with symptomatic kidney stones and found Flomax better than usual therapy (time difference
2.5 days); in large stones (>1 cm) or “stuck” distal stones, Flomax beneficial; also beneficial in people who have had
lithotripsy
|
| Laryngoscopy: Levitan looked at various ways of performing laryngoscopy and percentage of glottic opening (POGO)
score; 1100 different laryngoscopic views on fresh cadavers; bimanual method found most effective, as shown by POGO
score
|
| Coffee vs nap: 12 participants; randomized crossover study; participants awake all day and at 2 AM, asked to drive on
straight road for 1.5 hr (200 km), keeping constant speed and staying in one lane; subjects randomized to 30-min nap,
decaffeinated coffee, or caffeinated coffee; found less crossing of lines with nap
|
| Hangovers: systematic review of published trials looking at treatment and prevention of hangovers; agents tested included
propranolol, nonsteroidal anti-inflammatory drug (NSAID), 5-hydroxytryptamine (5-HT) receptor blocker,
glucose, fructose, artichoke supplement, and prickly pear supplement; found positive results only with NSAID and
these were dubious; concluded that abstinence or moderation only effective methods of preventing hangover
|
Suggested Readings
Bartlett JG: Narrative review: the new epidemic of Clostridium difficile-associated enteric disease. Ann Intern Med
145:758, 2006; Bijur PE et al: Intravenous morphine at 0.1 mg/kg is not effective for controlling severe acute pain in
the majority of patients. Ann Emerg Med 46:362, 2005; Clement CM et al: Clinical features of head injury patients
presenting with a Glasgow Coma Scale score of 15 and who require neurosurgical intervention. Ann Emerg Med 48:245,
2006; Green DA et al: Randomized comparison of pain perception during radial head subluxation reduction using supination-flexion
or forced pronation. Pediatr Emerg Care 22:235, 2006; Jeyaratnam D et al: Community associated
MRSA: an alert to paediatricians. Arch Dis Child 91:511, 2006; Lemmens HJ et al: The dose of succinylcholine in
morbid obesity. Anesth Analg 102:438, 2006; Levitan RM et al: Assessment of airway visualization: validation of the
percentage of glottic opening (POGO) scale. Acad Emrg Med 5(9):919, 1998; Macias CG et al: A comparison of supination/flexion
to hyperpronation in the reduction of radial head subluxations. Pediatrics 102:e10, 1998; McDonald J et
al: Radial head subluxation: comparing two methods of reduction. Acad Emerg Med 6:715, 1999; Moran GJ et al:
Methicillin-resistant Staphylocccus aureus infections among patients in the emergency department. N Engl J Med
355:666, 2006; Nabulsi MM et al: Alternating ibuprofen and acetaminophen in the treatment of febrile children: a pilot
study [ISRCTN30487061]. BMC Med 4:4, 2006; Naguib M et al: The dose of succinylcholine required for excellent
endotracheal intubating conditions. Anesth Analg 102:151, 2006; Nguyen HB et al: Early goal-directed therapy, corticosteroid,
and recombinant human activated protein C for the treatment of severe sepsis and septic shock in the emergency
department. Acad Emerg Med 13(1):109, 2006; Otero RM et al: Early goal-directed therapy in severe sepsis
and septic shock revisited: concepts, controversies, and contemporary findings. Chest 130:1579, 2006; Peake S et al:
Early goal-directed therapy of septic shock: we honestly remain skeptical. Crit Care Med 35:994, 2007; Pepin J et al:
Emergence of fluoroquinolones as the predominant risk factor for Clostridium difficile-associated diarrhea: a cohort
study during an epidemic in Quebec. Clin Infect Dis 41:1254, 2005; Quinn J et al: Prospective validation of the San
Francisco Syncope Rule to predict patients with serious outcomes. Ann Emerg Med 47:448, 2006; Quinn JV et al:
Derivation of the San Francisco Syncope Rule to predict patients with short-term serious outcomes. Ann Emerg Med
43:224, 2004; Rhodes A et al: Early goal-directed therapy: an evidence-based review. Crit Care Med 32:S448, 2004;
Sarrell EM et al: Antipyretic treatment in young children with fever: acetaminophen, ibuprofen, or both alternating in
a randomized, double-blind study. Arch Pediatr Adolesc Med 160:197, 2006; Sarrell M et al: Physicians', nurses', and
parents' attitudes to and knowledge about fever in early childhood. Patient Educ Couns 46:61, 2002; Smits M et al:
External validation of the Canadian CT Head Rule and the New Orleans Criteria for CT scanning in patients with minor
head injury. JAMA 294:1519, 2005; Stiell IG et al: Comparison of the Canadian CT Head Rule and the New Orleans
Criteria in patients with minor head injury. JAMA 294:1511, 2005; Sun BC et al: External validation of the San Francisco
Syncope Rule. Ann Emerg Med 49:420, 2007
Kaiser Permanente’s 17th Annual Emergency Medicine Conference will be held November 11-13, 2007, in Santa
Rosa, CA. For more information visit: www.mbdmeetings.com.
Educational Objectives
| The goal of this program is to update the clinician about the latest studies in emergency medicine. After hearing and assimilating
this program, the clinician will be better able to:
|
 | 1. Prescribe an adequate dose of morphine to control severe pain.
|
| 2. Manage fever in children, using alternating ibuprofen and acetaminophen.
|
| 3. Diagnose and treat community-acquired methicillin-resistant Staphylococcus aureus.
|
| 4. Recognize the growing problem of Clostridium difficile-associated diarrhea.
|
| 5. Discuss the efficacy of tamsulosin for kidney stones.
|
Faculty Disclosure
In adherence to ACCME Standards for Commercial Support, Audio-Digest requires all faculty members to disclose relevant
financial relationships within the past 12 months that might create any personal conflicts of interest. Any identified
conflicts were resolved to ensure that this educational activity promotes quality in health care and not a proprietary business
or commercial interest. For this program, the faculty reported nothing to disclose.
Acknowledgements
Dr. Tomaszewski was recorded at the 17th Annual June Jam, held June 9-11, 2006, in Myrtle Beach, SC, and sponsored
by the North Carolina College of Emergency Physicians. Dr. Birnbaumer was recorded at the 16th Annual Emergency
Medicine Conference, held September 13-16, 2006, in Las Vegas, NV, and sponsored by Kaiser Permanente. The Audio-Digest
Foundation thanks the speakers and the sponsors for their cooperation in the production of this program.
|
