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Thanks to Grand Rounds speaker Dr. Gail D’Onofrio — her talk on rapid and effective alcohol use assessment and counseling for ED patients is online (many of this year’s Grand Rounds lectures are collected under the ‘conference’ tab).

Also thanks to Evelyn, whose Senior Lecture on US-guided regional anesthesia generated interest. Some of her links for futher information, anatomic diagrams, and sono screencaptures  are below:

www.usra.ca
www.nysora.com
neuroaxiom.com
www.emcrit.org

As a counter to my procedural sedation lecture, I mentioned a recent Academic EM systematic review on the superiority of intraarticular lidocaine over IV procedural sedation for shoulder reductions. The link is here (Acad Emerg Med. 2008 Aug;15(8):703-8, PMID 18783486) and key findings are below. While not a comparison of regional anesthesia, it’s nonetheless provocative and suggests we should be doing it more.

Six Level 1 RCTs were identified. No studies showed a statistically significant difference in success rate between IAL versus IV sedation. The complication rate was significantly higher in the IV sedation groups (p < 0.001), and the total time spent in the ED was longer for the IV sedation group. CONCLUSIONS: The use of IAL for reduction of anterior shoulder dislocations should be strongly considered as a first line therapy because it is effective and safe and may potentially reduce time spent in the ED.

Real comparisons between regional anesthesia and procedural sedation have been done, too. One by (Pediatr Emerg Care. 2006 Oct;22(10):729-36, PMID: 17047473) rated axillary block in kids with shoulder dislocations as more cost effective than fentanyl / midazolam sedation but less cost-effective than propofol / fentanyl. 

Finally, Kit raised a couple of interesting points I wanted to address. During Neuro board review, a question on akathesia came up — apparently a professional BR course said that the first-line choice for treating akathesia induced by anti-emetics is a beta blocker, not diphenhydramine or cogentin.

I can’t find anything to support this assertion in the literature. In fact, recent studies have looked at whether diphenhydramine should be given as prophylaxis with metoclopramide:

J, Esses D, Bijur P, Gallagher EJ. Ann Emerg Med. 2008 Sep 22. PMID: 18814935

Two hundred eighty-nine patients were randomized and 286 patients were included in the final analysis. Within 1 hour of medication administration, 17 of 143 patients randomized to diphenhydramine (12%; 95% confidence interval [CI] 8% to 18%) and 17 of 143 (12%; 95% CI 8% to 18%) randomized to placebo developed akathisia (95% CI for difference of 0%: -8% to 8%). Thirteen of 143 patients randomized to metoclopramide 10 mg (9%; 95% CI 5% to 15%) and 21 of 143 randomized to metoclopramide 20 mg (15%; 95% CI 10% to 22%) developed akathisia (95% CI for difference of 6%: -2% to 14%). In those administered prophylactic diphenhydramine, odds of akathisia relative to placebo were 1.0 (95% CI 0.5 to 2.0). Odds of akathisia in those administered 20 mg of metoclopramide relative to the 10-mg dose were 1.7 (95% CI 0.8 to 3.6). Among patients who received 20 mg of metoclopramide, subjective restlessness was reported by 7 of 72 (9.7%) patients who received diphenhydramine and 14 of 71 (19.7%) patients who received placebo (95% CI for difference of 10%: -2% to 22%). CONCLUSION: Routine prophylaxis with diphenhydramine to prevent akathisia is unwarranted when intravenous metoclopramide is administered over 15 minutes. For patients administered 20 mg of metoclopramide, prophylactic diphenhydramine may decrease subjective restlessness.

Kit also asked about the value of amylase in assessing neck trauma. I couldn’t find any direct relevant data but recalled a study from my talk last year on blunt abdominal trauma, the lessons of which have some bearing here:

Greenlee T, Murphy K, Ram MD. Am Surg. 1984 Dec;50(12):637-40.  Amylase isoenzymes in the evaluation of trauma patients. PMID: 6210005

In traumatized patients, elevation of the levels of serum amylase is often noted and may lead to a diagnosis of pancreatitis or pancreatic injury. In the presence of multiple injuries, it is often difficult to evaluate clinically for pancreatitis or pancreatic injury. Since the serum amylase is derived from both the pancreatic and the salivary glands, it is useful to determine the origin of the elevated levels of serum amylase in these patients. A total of 31 patients including 21 trauma patients were studied, and the total serum amylase and also the pancreatic (P) and salivary (S) fractions were determined by isoelectric focusing. Compared with the normal control group, most trauma victims had elevated total amylase levels (normal, 30-128 U). In six patients with head and facial trauma, the P-fraction was 7.6 per cent, and the S-fraction was 92.4 per cent (normal, P 35-50%; S 50-65%), while in six patients with penetrating abdominal trauma, the P-fraction was 81 per cent, and the S-fraction was 19 per cent. These differences were statistically significant. The data demonstrate the value of measuring fractions of amylase in addition to total amylase levels. In patients with head and facial trauma alone, elevated levels of serum amylase are due to an increase in the salivary fraction. Elevation of total serum amylase in traumatized patients does not necessarily indicate pancreatic injury. Measurements of amylase fractions were thus useful in evaluation of trauma patients.

Other references all agree that amylase can rise even after nonabdominal trauma or surgery, as a market it seems nonspecific.

Comments, as always, are welcome.

Posted on Thursday, October 9th, 2008 at 10:47 am by Nick. Filed under Trauma, Post-Conference Letter, Sedation, Pain Management, Procedures, Blog.
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