sinaiem.org

Thanks to everyone who attended my first Sinai conference. I’d like to provide some follow-up regarding some of the issues that we discussed today:

Antibiotics during COPD exacerbation: Antibiotics are indicated with severe exacerbations and those with increased sputum production as recommended by all major thoracic societies (even the Brits and Canadians!) based on randomized-controlled data. There was a discussion about choice of antibiotic. To date, there have been 11 RCTs comparing different agents in different clinical settings that show statistically significant improvement in the primary outcome measure (LOS, mortality, decreased sputum production) compared to placebo. Though most studies were done a while ago, the most recent study in 2001 (PMID: 11755608) compared ofloxacin in ventilated, non-pneumonia COPD patients who were randomized to 400mg PO vs placebo via NGT (!) (this study was done in Tunisia, might be hard get this study past some IRBs). This study showed a reduction in in-hospital mortality with an impressive ARR of 17.5% which when inverted yields a NNT of 6. Take home message: start an antibiotic (choose your favorite) on your sicker, sputum-ier COPD patients. If they have PNA, treat it.

Use of ipratropium, magnesium, and SQ terb in asthmatics: A side conversation that not everyone may have heard focused on the evidence behind the use of atrovent, mag, and SQ terb in asthmatics. Evidence exists to support the use of atrovent in both adults and children in improving peak flow and ED LOS, although evidence supporting decreased admission rates is not as strong. (PMID: 7699549 & 10103297). Magnesium has been shown to reduce hospital admission only in a subgroup of severe asthma exacerbations and thus cannot be recommended for routine use. The dose in adults is 2g IV and in children is 25 to 100 mg/kg IV. (PMID: 2879458 & 896972). As for SQ terb, I couldn’t find any evidence substantiating it’s use, although lots of people like to recommend it in the literature (I even used it about a month ago - on someone 58 years old - but the BiPap saved that patient from the tube, not the terb). Bottom line: always on the atrovent, maybe on the mag, and no evidence for the terb.

That’s it for now. See you all next week, if not before.

Thanks to all who stopped by our Innovations inEM Education booth at SAEM these past few days. Your input and encouragement were appreciated! The abstract is now online and an MS-Word version of our informational pamphlet is available for download.  

 For those of you who wanted to discuss things further, my email is Nicholas.Genes /at/ mssm.edu.

Other EM journal club websites with analyses of articles:

• Washington University (archives)
• University of Michigan (archives)
• Emory (archives)
• East Virginia Medical School

If you know of more, please share! The idea of putting EM Journal Clubs online, for prompt bedside access, goes back a few years…

At our last Journal Club, Tom presented a 2005 paper from JEM on new CT scanners in the evaluation of SAH. The paper was called Subarachnoid Hemorrhage Diagnosis By Computed Tomography and Lumbar Puncture: Are Fifth Generation CT Scanners Better at Identifying SAH? by Boesiger and Shiber, and it appears in Journal of Emergency Medicine (2005: Vol. 29, No. 1 pp23-27).

The article is motivated by the fact that 1% of headache patients in the ED have SAH. Most are traumatic, but those that aren’t are usually from Circle-of-Willis aneurysm ruptures, which often kill or disable otherwise healthy people. EM physicians hate that sort of unsettling risk, and the situation is further complicated by the 20-50% of SAHers who present with a sentinel bleed. So there’s a real opportunity to help some potentially moribund patients —  but if you ask most interns, they’ll say they’re shoving too many needles into the backs of people who probably just needed some exedrin.

Maybe we can change our practice, based on recent upgrades in CT scanner technology. These authors were the first to look at the new scanners with an eye toward sensitivity in SAH diagnosis. More below…

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