Keeping Abreast in Emergency Medicine

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Keeping Abreast in Emergency Medicine

• Ed C. Cabigao, MD, FACEP
• Assistant Professor
• Division of Emergency Medicine
• Regional Medical Center (THE MED)
• University of Tennessee Health Science Center
• Memphis, Tennessee

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CT of the Head Before Lumbar Puncture in Adults
with Suspected Meningitis

• NEJM, Dec. 2001 - Hasburn R, Abrahams J, Jekel J,
  et al
• Study looked at clinical prediction of patients
  that needed CT prior to LP
• If none of the clinical features was present, CT
  was not needed before LP
• If patient had no altered MS, focal neuro
  deficit, recent seizures or history of CNS
  disease, CT is not needed before LP.

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Treatment of Acute Ischemic Stroke

• Annals of EM, Feb. 2001 - Lewandowski C, Barsan W
• A review of ischemic stroke
• If thrombolytics are given, strict guidelines
  must be followed
• Use of NIH stroke scale is required
• BP guidelines are discussed using Nitro paste or
  IV Labetalol
• The highest risk for using rTPA is intracerebral
  hemorrhage
• BP must be less than 185/110 mm HG within one
  hour of treatment or NO rTPA

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Intravenous Nesiritide vs. Nitroglycerin for
Treatment of Decompensated CHF A Randomized
Controlled Trial

• JAMA, March 2002 - Young JB
• Compared hemodynamic data (PWP) and self report
  of dyspnea
• 489 patients, 286 got PA cath
• Nesiritide better for PCWP
• Nesiritide more helpful in patients with CHF
  CKD
• Same results for symptomatic relief of dyspnea

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Dexamethasone in Adults with Bacterial Meningitis

• NEJM, Nov. 2002 - deGans J, van de Beek D
• Prospective random double-blind study Abx /-
• Bacterial lysis produces inflammation in
  subarachnoid space
• Fewer deaths, less seizures, less
  cardiorespiratory failure
• No effect on neuro/hearing loss
• Adverse effects rare
• Effects more prominent in pneumococcus
• Dexamethasone 10 mg IV immediately before
  antibiotics reduces adverse outcomes in bacterial
  meningitis

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Validation of the Ottawa Knee Rules in Children A
Multicenter Study

• Annals of EM, July 2003 - Bulloch B, Neto G, et
  al
• Determine sensitivity specificity
• See if it would decrease x-rays
• Valid in children with a 100 sensitivity/43
  specificity and reduced need for x-ray 31.
• Knee Rules (when to x-ray)
• Tenderness at head of fibula
• Isolated tenderness of patella
• Inability to flex the knee 90 degrees
• Inability to bear weight immediately and in the
  ER ( 4 steps )

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Evaluation and Management of Febrile Seizures in
the Out-of-Hospital and ED Settings

• Annals of EM, Feb 2003 - Warden CR, Zibulewsky J,
  Mace S, et al
• Most common cause of seizure lt 5years, with a
  2-5 incidence
• NOT at increased risk for serious bacterial cause
• As in other febrile children, focus evaluation to
  exclude serious bacterial cause
• Febrile seizure T gt 38, 6 mos- 5 yrs, no other
  cause

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Evaluation and Management of Febrile Seizures in
the Out-of-Hospital and ED Settings

• Simple febrile seizure - lt 15 mins, generalized,
  1 per 24 hr. period
• Complex febrile seizure - gt 15 mins, focal,
  recurrent within 24 hr. period
• Simple febrile seizure needs no workup except
  blood glucose
• Antipyretics and cooling measures not effective
  at treatment or prevention

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Evaluation and Management of Febrile Seizures in
the Out-of-Hospital and ED Settings

• Strongly consider LP in children lt 18 months
• History of increased irritability, decreased
  feeding, lethargy
• Abnormal appearance or mental status after
  post-ictal period
• Prolonged post-ictal period
• Complex febrile seizure
• Signs of meningitis
• Pretreatment with antibiotics
• CT indications
• Cannot exclude increased intracranial pressure
• Status epilepticus or complex febrile seizure
• History of trauma or VP shunt

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Trauma in Pregnancy

• EM Clinics of N Amer, Aug 2003 - Shah AJ,
  Kilcline BA
• Prehospital care to include tilting backboard 15
  degrees to the left
• Usual aggressive fluid resuscitation
• Necessary radiographs should not be witheld at
  any period of gestation. Radiation beyond 20
  weeks gestation is safe.
• 60 blunt trauma from MVCs
• Most common cause of fetal death is maternal
  death
• Placental abruption is most common cause of fetal
  death if mom survives

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A Risk Score to Predict Arrhythmias in Patients
with Unexplained Syncope

• Acad Emerg Med, Dec 2003 - Sarasin FP, Hanusa BH,
  Perneger T, et al
• 179 patients with unexplained syncope
• Attempted to build a risk score predicting
  arrhythmia
• Prevalence of arrhythmic syncope was 18
• Predictors of arrhythmia were
• Abnormal ECG - AF, sinus pause, sinus brady b/
  35-45, conduction disorders, signs of old MI or
  hypertrophy, multiple PVCs
• History of CHF
• Age older than 65

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A Risk Score to Predict Arrhythmias in Patients
with Unexplained Syncope

• Patients at risk should be admitted with
  continuous cardiac monitoring and get an
  echocardiogram
• Patients with syncope and no risk factors, normal
  ECG and physical exam can be discharged home and
  have outpatient follow up.

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Womens Early Warning Symptoms of AMI

• Circulation, Nov 2003 - McSweeney JC, Cody M, et
  al
• A study which describes prodromal symptoms in
  women before AMI. Survey of 515 women following
  AMI.
• Fatigue - most common prodromal symptom in weeks
  leading to AMI ( 71 )
• Sleep disturbance and SOB were next most common
• Only 29.7 reported chest discomfort as a
  prodromal symptom

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Sterile vs. Non-sterile Gloves for Repair of
Uncomplicated Lacerations in the ED

• Annals of EM, Mar 2004 - Perelman VS, Francis GJ,
  Rutledge T, Foote J, et al
• Study looked at infection rates comparing the use
  of sterile vs. non-sterile gloves in
  uncomplicated traumatic lacerations
• 3 large community hospitals in Toronto
• High pressure irrigation is best way of cleaning
  wounds
• History of renal failure increases chance of
  infection
• No clinically important difference found

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Oral Agents for the Treatment of Type 2 Diabetes
Mellitus Pharmacology, Toxicity and Treatment

• Annals of EM, July 2001 - Harrigan RA, Nathan MS
• Discussed oral agents for Type 2 DM
• Sulfonylureas work by increasing insulin
  production
• Octreotide can be used as an adjunct to glucose
  therapy in cases of refractory hypoglycemia
  caused by sulfonylurea poisoning
• Glyburide, Glucotrol XL and Chlorpropamide cause
  prolonged decrease in glucose
• Bactrim, Floxins, H2 blockers increase likelihood
  of hypoglycemia if added to sulfonylureas

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Cocaine Associated Chest Pain How Common is
Myocardial Infarction ?

• Academic Emerg Med, Aug 2000 - Weber JM,
  Chudnofsky CR, Boczar M, et al
• Study sought incidence of AMI in cocaine
  associated chest pain
• Incidence is 6
• Most common complaint is pressure/heaviness
• Atypical also common
• Dyspnea is most common symptom
• gt 25 with diaphoresis and nausea
• Only 27 of ECGs were normal
• Most common ECG finding --gt non-specific changes
  (50)

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New Diagnostic Tests for Pulmonary Embolism

• Annals of EM, Feb 2000 - Kline J, Johns K, et al
• Overview of screening tests and confirmatory
  tests for PE
• Review of many articles in the literature
• Concluded that 2nd generation D-Dimer tests are
  very sensitive
• Spiral CT is a very good confirmatory test
• If symptoms of PE are present more than 7 days,
  D-Dimer is not reliable
• MRI is a good test for PE in the pregnant patient
• In a patient with dyspnea and risks for PE and a
  D-Dimer, order a CT of the chest

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Therapeutic Controversies in Severe Acute Asthma

• Academic Emerg Med, Jul 2000 - Gibbs MA, et al
• No benefit of IV over PO steroids
• Early steroids important
• Continuous nebs are more effective than
  sequential nebs only in severe asthma
• Xopenex gives more bronchodilation than albuterol
• Magnesium 1.2 - 2.0 gm IV over a 20 minute period
  may help in a severe attack

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The End