Several residents complained in the comments section, and the term “nihilism bias” was coined. Months went by, but on the night of St. Patrick’s Day, the editor-in-chief of Journal Watch and a leading figure in EM jumped into the fray and advised us that changing practice based on a single, small study is not the kind of care he teaches or wants to be subjected to.

Steroids in headache, which had been a hot topic at SAEM last year and subject of some additional trials in the interim, was addressed again in Journal Watch this week. The very same editor reviewed a new meta-analysis of dexamethasone for acute migraines (Colman, BMJ 2008 Jun 14; 336:1359) and wrote:

“…The authors conclude that when added to standard acute migraine treatment, a single parenteral dose of dexamethasone is associated with a 26%reduction in headache recurrence within 72 hours. An accompanying editorial notes that patients with diabetes should be treated with caution because of the potential for prolonged elevation of blood sugar…

Despite the limitations of a meta-analysis, these results suggest that a single dose of dexamethasone is a reasonable addition to the treatment of acute migraine episodes that has little downside for patients without contraindications to steroids. Although dexamethasone had no benefit for initial pain relief, the number needed to treat to prevent one recurrence was only 9, suggesting that treatment has significant potential to help patients remain functional and avoid repeat emergency department visits. This study tested only parenteral administration, but an oral dose might be just as effective in nonvomiting patients.”

Perhaps a lot has changed in 18 months, perhaps not so much (the Baden 2006 study that was the basis of our original journal club was the smallest in the meta-analysis, and showed the most favorability of dexamethasone), but one things for sure — you can now order a dose of dex with a clear conscience.

As for the resident and fellow presentations on central DI and general pediatric endocrine emergencies (thank Marisa and Karen, respectively), well, there’s not too much I can add, other than to check EMPeds.com for dosing information and sources like UpToDate, and online free text Pediatric Endocrinology for more background on presentation, diagnosis and treatment.

But for Dr. Jagoda’s provocative lecture on TBI and the upcoming ACEP clinical policy, see below.

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This seems like an excellent opportunity for us, as there could be many orthopedic and non-orthopedic injuries. They’re pretty good teachers for sports-medicine type injuries but I suspect they’ll lean on our expertise for heat exhaustion, aspiration, and who knows what else.

Geordi Gantseodes is involved, and Mark Klion is the ortho in charge.  His email: bcrusher@aol.com

They are planning to meet at 5:30 AM at the 79th St Boathouse (you will be familiar with this locale after the retreat next week).  There will be a medical tent there.  The triathlon should last until 12 or 1 PM.

More triathlon info is available online.

If you’ve got some stories like this, let me know and I’ll put you in touch with him.

Our first talk of the year was given by Ram, who lectured on penetrating chest trauma. Below are some points that merit repeating:

• - Unstable patients with stab wounds to ‘the box’  are either hypovolemic, have PTX, or tamponade. So get some blood ordered and get an ultrasound probe.
• - Pericardiocentesis is a pretty cool procedure that has almost no role in trauma at academic centers. The volume of blood that causes tamponade physiology is scant in trauma, and even if you can aspirate that blood, it will rapidly reaccumulate. For medical effusions, pericardiocentesis can be more easily done by ultrasound guidance — I refer the reader to p76 of Dr. Nelson’s ultrasound book, or to Dr. Hoffman’s website.
• - Ram pulled a great slide from Degiannis 2006 (PMID 16773259, figure 1) that lays out your options in penetrating cardiac trauma in various clinical scenarios. After PTX has been ruled out, the lifeless patient needs endotracheal intubation and ER thoracotomy. Accept it, and it will be easier to cut. Dr. Weingart has reviewed this procedure on his website, and he has also listed other indications and contraindications for thoracotomy.

Dr. Rabin delivered her core lecture on emergencies in malignancy.

• - Neutropenic fever is defined as an absolute neutrophil count below 500 and a temperature of 38.4C (or over 38C for more than an hour). Calculating ANC is easy (this calculator and others can be found under the ‘Clinical’ tab above). The admonition to avoid rectal temps in neutropenic adults is not evidence-based, though digital rectal exams remain contraindicated.
• - Work with the patient’s oncologist in deciding ABx therapy in neutropenic patients. Vancomycin should be avoided unless indicated by cultures, course or instability.
• - Be vigilant for tumor lysis syndrome: Order a uric acid and PO4 level on your chemo patients with nonspecific symptoms. Obviously you’ll get a potassium and treat hyper-K appropriately (perhaps avoiding Ca++ unless absolutely necessary) but the urate will need urine alkalinization, and high PO4 gets phosphate binders, plus insulin+glucose.
• - Hypercalcemia (stones, moans, bones, psych overtones) needs treatment if the patient is symptomatic or over 14 mEq. Correct the calcium if the patient’s hypoalbuminemic. Treat with hydration, lasix (after hydration), bisphosphonates, and dialyze if AMS or ARF.
• - Finally, be vigilant for DVT/PE, SVC, and spinal cord mets (said to manifest with back pain that’s worse upon lying down).

Dan presented the first (and second) M+M of the year. He gave a nice introduction to the various kinds of error we are prone to, and how cheese is the answer.

• - Dan also took us through the crash airway, difficulty airway, and failed airway algorithms (you should have a copy of Ron Walls’ book, and parts are freely available online).
• - Like our reluctance with thoracotomy, cricothyroidotomy is something we have to expect, so that it’s easier to cut when we have to. Here’s the NEJM cricothyroidotomy video. Youtube has other videos. And for the hardcore among you, here’s a keychain cric kit I once blogged about.
• - While we can recognize the importance of neuro status checks for our colleagues in neurosurgery, sedating intubated patients is crucial, especially with more planned trips to the CT scanner. The agent of choice? Propofol (the milk of oblivion — rapid on, rapid off, and recommended by the BTF for ICP control). And if propofol is lowering the BP, well, this is one time where pressors in trauma makes sense.

If you want to address some of the topics above, or other aspects from conference, please comment below.

Thank you to those of you who passed up Ponte Vedra or new jobs to come to conference this week. Many thanks to our resident speakers, Matt, Shefali and Bing, and to our faculty presenters — Dr. Spina and Dr. Nassisi. Also thanks to the neurology department for their participation in our joint conference.

Below are some topics from conference that for which I found more resources, or that I just thought warranted repeating.  Feel free to add your own thoughts in the comments section.

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We had an enjoyable conference this week. Thank you to our resident speakers, Sheler and Shawn, and to our faculty presenters — Dr. Ginsburg, Dr. Strayer, Dr. Weingart and Dr. Andrus. Also thanks to the cardiology department for their participation in Sheler’s joint conference, and to Sohan, our graduating conference chief, who was on hand to lend his expertise with AV and other issues.

Below are some topics from conference that I wanted to touch upon — stuff that struck my fancy, really. Feel free to add your own in the comments section below.

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Sohan discussed the original PERC rule derivation paper and its recent validation — the papers below are accessible using our password system:

Kline JA, et al. Clinical criteria to prevent unnecessary diagnostic testing in emergency department patients with suspected pulmonary embolism. J Thromb Haemost 2004; 2: 1247–55. (PMID: 15304025)

Kline JA, et al. Prospective multicenter evaluation of the pulmonary embolism rule-out criteria. J Thromb Haemost 2008; 6: 772–80. (PMID: 18318689).

Sohan started with a lit review, going back to DeBakey’s 1954 discussion of 3 million PE’s, where it was first noted that PE is tough to diagnose and its prevalence is unclear. Even now, very little has changed. We don’t know the true incidence, we don’t know how many we miss, we don’t know which PE’s are clinically relevant, and we don’t know when to pursue this diagnosis. Even the Well’s criteria, which I mentioned here a couple of years ago, are not too clean — because they give more points to the physician’s judgment than to any other sign or lab result.

So we’ve been left with the unfortunate, all-to-common situation of considering D-dimers for every poor patient who presents with vague chest discomfort or dyspnea. If that dimer is positive, and it often is falsely so, we’re forced down a road of angiography , contrast, radiation, and other potential sources of morbidity.

Is there a way out of this? Is there a simple decision rule we can apply, at the bedside, using nothing but history and physical, to prevent this unnecessary testing?

Kline et al thought so — and the rule they proposed is discussed below. (more…)

The first is EM Peds,  Mark’s masterful new pediatric emergency medicine website. One-stop shopping for calculators, med options and dosing, clinical algorithms, and more. It’s found a permanent home now under this site’s ‘clinical’ tab, but check on it often.

Also,  Ted highlighted a bunch of sites worth visiting. He points us to the EM Foundation grant application page, the ACEP chapter grant page, and the guide to section grants. He also showed a list of awards available to EM residents, that I’m happy to share with you over email. There’s also this nifty SAEM website on resident resources.

For the teacher in all of us, visit residentteachers.org for some tips and videos on how to be a more effective educator. For the businessperson in all of us, consider the emcare conference for senior residents.

A quick review of nephrolithiasis. The most general approach to these patients is pain control followed by urinalysis. As was mentioned at conference, pain control is best achieved with combination therapy using an NSAID such as ketorolac and narcotic such as morphine (PMID: 16953530). If the clinical presentation is correct and urinalysis shows blood, imaging is not necessary. Here’s the first problem: the “classic” finding of hematuria can be absent up to 15% of the time (PMID: 7747369).

In cases which the diagnosis is not as clear, non-contrasted CT scan of the abdomen is indicated and proves to be a very good test for nearly all renal stones except for those secondary to HIV protease inhibitors such as indinavir (PMID: 9230000). So that’s great because unless we are dealing with that specific situation, the non-contrasted CT scan should certainly find the stone. But invariably that sometimes doesn’t happen, which brings up the second problem: what now?

At this point the arrow starts to point further down the differential and a diagnosis of pyelonephritis comes to mind given the patient’s bloody urine, positive leukocyte esterase, and mild flank tenderness. While pyelo is a clinical diagnosis supported by a characteristic urine, often muddled histories and unconvincing exams can leave the diagnosis in doubt. Non-contrasted CT scans can show an enlarged kidney or perinephric fat stranding indicative of a pyelo, but they can also be normal in the setting of pyelo. Thus in the patient with an unclear diagnosis based on urine and history and non-diagnostic CT scan, a contrasted CT scan should be pursued as the next step(PMID: 16937102, 15486235). Besides giving a much better image of the kidney in cases where the diagnosis is in doubt, a contrasted scan will highlight vascular diseases or renal infarcts whose presentations mimic that of renal colic and would not be seen on a non-contrasted scan. These are rare entities but can be missed easily. Bottom line: slog through getting 2 CT scans when kidney stones are not seen on the initial non-contrasted CT and the clinical picture is not a slam dunk for pyelo - the correct imaging for pyelo should be with IV contrast.