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Drs. Nelson, Baumlin and Basavaraju wrote up an interesting case that was featured in the Correspondence section of the September 2006 Annals of Emergency Medicine (Vol. 48, No. 3, pp339-340). The letter was titled, Sonographic Diagnosis of Axillary Artery Aneurysm Presenting As Painful Axillary Mass and features some vivid photos. The summary is excerpted below:

Although the assessment of abdominal aortic aneurysms has long been a standard indication for bedside ultrasound, this case represents a previously unreported presentation (possible abscess) of a rare condition (axillary artery aneurysm). In this case, rapid assessment using bedside ultrasonography was able to unequivocally exclude abscess from the differential diagnosis, and allow the proper consultants to become involved earlier in the course of the ED visit. Furthermore, identification of the axillary artery aneurysm led to obtaining a computed tomography scan which revealed a larger and potentially lethal aortic aneurysm. Although it is unlikely that an emergency physician would have attempted to incise and drain a pulsatile “abscess,” it is useful to distinguish a mass impinging on a vessel from a mass which is a vessel.

Incidentally, the letter to Annals immediately following this one is from a former classmate. It is indeed a small EM world.

Given our recent guest speaker and spirited discussion, I thought it would be worthwhile to discuss a review from the September ‘06 Annals: the Use of Noninvasive Ventilation in ED Patients with Acute Cardiogenic Pulmonary Edema. We know ACEP will soon be publishing a new clinical policy on heart failure, it’ll be interesting to see how their interpretation of the literature squares with that of Collins et al.

And, even though we’ve all seen these masks in action, it’s probably worth repeating that CPAP is continuous positive airway pressure, regardless of inspiration or expiration. CPAP has been shown to reduce the work of breathing and decrease LV afterload, while maintaining cardiac index.

Noninvasive positive pressure support — sold under the trade name BiPAP – works similarly, but with less positive pressure during exhalation; it’s inspiratory pressure support plus PEEP (this variant called C-Flex kind of demonstrates it, but with an exhalation pression of zero). In theory, BiPAP should reduce the work of breathing even more than CPAP, and physiologically would seem to be of more benefit in obstruction airway disease (asthma, COPD).

For a more in-depth review of the mechanisms, indications and contraindications, check out this eMedicine article. For a practical guide with some key citations, see EMCrit.org. Basically, both CPAP and BiPAP work in part by raising intrathoracic pressure, which decreases preload AND afterload (which probably benefits patients with cardiac dysfunction). Neither therapy is definitive for cardiogenic pulmonary edema; they’re temporizing measures while your nitrates and diuretics kick in.

Previous studies have shown that CPAP decreases intubation rates in patients with acute cardiogenic pulmonary edema (ACPE). A systemic review in 1998 bolstered the claim, but that review included trials with non-ED patients.

The first big BiPAP study (Mehta, 1997) showed an increase in respiratory function and hemodynamic improvement compared to CPAP, but similar rates of mortality in hospital, and similar intubation rates. Plus, notably, the BiPAP patients experienced more MI! (it’s worth noting that that arm of the study received, by chance more patients complaining of substernal chest pain, and a 2004 study comparing CPAP and BiPAP showed no difference in MI).

Since then, many small trials between CPAP and BiPAP suggested no difference between these noninvasive ventilatory modes compared to standard-of-care, which other studies suggested a decrease in intubation and mortality. But this paper is the first systematic review of CPAP and BiPAP in ED ACPE patients.

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Dinali did a stellar job this month at Journal Club; not only was her talk thought-provoking and clinically relevant, but I learned more about the history of of our world’s 8th most abundant element than I would have ever thought possible.

This month’s JC was primarily about Davey and Teubner’s AEM paper on using Magnesium sulfate as an adjunct to “usual care” for rate control in atrial fibrillation (AEM Vol 45, No 4, April ‘05, p347-353). We also touched upon some data from an all-Greek study in the Int’l Journal of Cardiology on Mg alone vs diltiazem alone in A-fib (Chilidakis, IJC 79 2001 p287-291).

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This week’s New Yorker (our program’s most widely-read non-EM journal) has a fun article about Jones fractures and fifth metatarsal avulsions. Apparently, the latter are exceedingly common on Martha’s Vinyard in the summer. And there’s just one orthopedist on that island, to see all of them. There’s more below, but a more scholarly review of mifth metatarsal fractures and avulsions can be found at Wheeless’ Orthopedic Dictionary, online. They’ve got Xrays and differentials and more than Tintinalli, so check it out.  

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Ah, the first Conference of the academic year. The new faces, with their bubbling enthisasm, suddenly confronted with the annual reading of the policies & procedures manual… why, it’s enough to give anyone a headache and photophobia. Which is why it’s so timely that we review meningitis, with a focus on some physical exam skills that can (but may not) help guide your diagnosis.

Tim reviewed a paper by Thomas et al out of Yale, published in Clinical Infectious Diseases (2002;Vol 35 July 1, pp46-52) called “The Diagnostic Accuracy of Kernig’s Sign, Bruzinski’s Sign, and Nuchal Rigidity in Adults with Suspected Meningitis.” Here’s his CAT sheet.

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I gave a talk last week on the workup of nonsevere sepsis that referenced a bunch of little papers, and a few big ones… We’ll leave the discussion of the landmark 2001 EGDT severe-sepsis talk for another time (sigh). Right now I just wanted to go over an Annals paper (AEM Vol 45, No 5, May ‘05) by Shapiro et al from Beth-Israel Deaconess, about lactate in the ED. They were looking at the value of ED serum lactate levels as a predictor of later mortality – echoing studies on ICU lactate and mortality for patients with septic shock, burns, or trauma.

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Dr. Hoxhaj gave a great presentation at the beginning of my intern year, on some of the top papers in emergency medicine published this . His criteria for excellence? They were either landmark works that changed EM practice, or well-conducted research with surprising conclusions that challenged dogma and made us think. Or, as he said, he's just messing with us.

Over the next few weeks, I'll post some of these papers here, as blog entries. Each post will have a link to the papers mentioned, plus some of his commentary gleaned from his slides. Feel free to add your own comments (especially if you're Dr. Hoxhaj).

The first papers I wanted to mention involve wound care — specifically, some novel, and maybe cavalier, ways of treating lacerations.

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Beth Y. Ginsburg just lectured us last week on the toxicology of anti-diabetic drugs… She was once a resident in our program and is now joining the crew at Elmhurst. She wrote, with Dr. Sharma, an article on umbilical hernia rupture and evisceration (pdf) in a recent JEM (Vol 30, No 2, Feb '06). Check it out!

By the way, JEM has pretty much cornered the market on articles about leaky belly buttons in recent months…

Oh yes, Conference Journal Club will be a duel this week, featuring two chiefs – nearing retirement, holding back nothing, fighting for their honor and their patients' cortex… Heads will roll.

Marc's paper is available here — it's a classic, the NINDS trial from 1995 (NEJM 333:1581-1587), predating Marc's arrival at Sinai (which historians believe occurred sometime during Clinton's second term). Many of the interns were still in high school in 1995, but otherwise, pretty much nothing has changed in medicine.

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