sinaiem.org

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:

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Dr. Lewis Goldfrank’s lecture on alcohol withdrawal is now up on the Conference page.  Give it another listen, as Dr. Goldfrank is a very engaging and provocative speaker. And be sure to review our own Dr. Olmedo’s chapter on withdrawal syndromes, which includes a great section on alcohol.

As for my senior lecture, there were many topics I didn’t get to include — so let me just point you to a few excellent articles and some practical tips:

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This week in journal club, Matt reviewed a nice little trial submitted by a group of Texans to the Canadian Journal of Emergency Medicine. They studied IV dexamethasone in preventing benign headache recurrence (Can J Emerg Med 2006;8(6):393-400, PDF) – something I had never tried, but apparently has been bouncing around the neurology and EM literature for 20 years.

It turns out that migraines may not be simply a vascular disorder, but rather an inflammatory disease. And, as Matt pointed out, it’s very difficult to diagnose migraines; it might be simpler for us ED folk to say headaches exist on a continuum between tension and migraine, and maybe ED patients with primary headache would benefit from a steroid.

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In the growing backlog of articles and journal club presentations I’d like to write up, I came across this publication which was presented a few months back — Does End-tidal Carbon Dioxide Monitoring Detect Respiratory Events Prior to Current Sedation Monitoring Practices? from Burton, Harrah, Germann and Dillon in Academic Emergency Medicine 2006; 13:500-504. My notes on the presentation have long since disappeared (I believe it was given by… Tim?) but my interest in the topic was rekindled after a recent M+M.

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We continue to make our way through the recent pain management papers, once again turning to the August Annals (Vol 48, No 2). Chang, Gallagher et al. strike back with a second analgesia piece in this issue — from now on, Montefiore will be simply be known as the House of Pain. The paper’s called Safety and Efficacy of Hydromorphone as an Analgesic Alternative to Morphine in Acute Pain: An RCT (if you’re logged into the Sinai library, full text is here). It’s full of provocative hypotheses, good study technique, and fun historical trivia… more below!

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I’m finally getting around to the some of the good articles on ED pain management that appeared this summer. The first was in the August 2006 Annals of EM, an article by Gallagher, Esses et al. entitled, “Randomized Control Trial of Morphine in Acute Abdominal Pain.” The authors tested the oft-repeated dictum that morphine affects diagnostic accuracy, measuring pain on a 0-100mm visual scale in a prospective double-blind random trial, giving 0.1 mg / kg of IV Morphine sulfate or placebo (ouch!) with an endpoint of “diagnostic accuracy” (ie, comparing the provisional diagnosis made by an emergency physician in 15 minutes after the agent is given, vs. diagnosis at six or more weeks of followup.)

They randomized 78 patients into the morphine arm, 73 into the placebo group. After fifteen minutes, the patients who got morphine changed their pain rating from 98 to 65, on average, whereas the placebo group went from 99 to 97. Diagnostic discordance occurred 11 times in each group, meaning that accuracy wasn’t affected by analgesia.

The dictum to avoid analgesia in abdominal pain dates to a 1921 proclamation by Sir Zachary Cope — a good example of emminence-based medicine. Maybe this warning was appropriate in the age before antibiotics and CT scanners, but we now have eleven trials in the last twenty years showing that Cope doesn’t cut it.

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