The Cutting Edge – PEs, Ultrasound, Pus, and more.

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In this episode, we summarize recent literature we feel is high yield, important, or frequently discussed in emergency medicine. As always, we encourage you to read the papers and not FOAM it alone.

Antibiotics and abscesses – Daum et al

FAST in hemodynamically stable patients –  Holmes et al

Haloperidol in gastroparesis – Roldan et al and Ramirez et al

Ignoring PERC – Buchanan et al

Steroids in non-asthma/COPD lower respiratory tract infections – Hay et alENDAO – Caputo et al

Gender pay gap persists in academic EM (and it’s not due to hours, rank, or roles) – Madsen et al

#dasSMACC – Airway Ultrasound, Critical Care, and Dunning-Kruger

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We are in Berlin for #dasSMACC and have lots of pearls to share from the speakers at this amazing conference.  Talks will be released for free on the SMACC podcast over the next year, but this podcast holds some pearls that we thought couldn’t wait.

Overall trope of the conference….

dasSMACC

for more on the Dunning-Kruger effect check out this post

Drs. Jacob Avila and Ben Smith on Airway Ultrasound

Check out this 7-minute video on ETT placement confirmation using ultrasound

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Dr. James Rippey on Point of Care Ultrasound Incidental Findings

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Dr. Jack Iwashyna on Persistent Critical Care

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FOAMcastini – Medical Texting

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We interrupt our normal core content to cover an important topic highlighted in JAMA’s recent article, “Medical Texting and Protected Health Information. What is permitted?

Protected Health Information

Other pearls:

  • Live tweeting is dangerous (exposes dates, potentially identifiable events)
  • If in doubt, leave it out

Reference:

Department of Health and Human Services. “Guidance Regarding Methods for De-identification of Protected Health Information in Accordance with the Health Insurance Portability and Accountability Act (HIPAA) Privacy Rule.” November 16, 2015

Suviving Sepsis Campaign Guidelines 2017

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The new Surviving Sepsis Campaign Guidelines are out in Critical Care Medicine.  The biggest change is the change in the definition of sepsis, which now uses the language of Sepsis 3.0, introduced in 2016. Other significant changes include dropping protocolized care (ex: early goal directed therapy), and recommending against combination antibiotic therapy (double coverage) for a single pathogen [1,2].

Bonus discussion on new validation study of qSOFA

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References:

  1. Opal SM, Rubenfeld GD, Poll T Van Der, Vincent J, Angus DC. The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3). 2016;315(8):801–10.
  2. Rhodes A, Evans LE, Alhazzani W, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Crit Care Med [Internet] 2017;1.
  3. Keh D, Trips E, Marx G, et al. Effect of Hydrocortisone on Development of Shock Among Patients With Severe Sepsis: The HYPRESS Randomized Clinical Trial. JAMA. 2016;316(17):1775-1785.
  4. Seymour CW, Liu VX, Iwashyna TJ, et al. Assessment of Clinical Criteria for Sepsis. Jama [Internet] 2016;315(8):762.
  5. Freund Y, LeMachatti N, Krastinova E.Prognostic Accuracy of Sepsis-3 Criteria for In-Hospital Mortality Among Patients W.ith Suspected Infection Presenting to the Emergency Department. JAMA. 2017;317(3):267-268.

Roundup: Favorite Literature of 2016

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Article highlights of 2016

Sepsis 3.0

Singer M, Deutschman CS, Seymour CW, et al: The Sepsis Definitions Task Force The Third International Consensus Definitions for Sepsis and Septic Shock (Sepsis-3).

  • This iteration of sepsis discarded systemic inflammatory response syndrome (SIRS), noting it’s poor discriminatory ability.  Further, these authors sought to define sepsis as a dysregulated response to infection, not just a normal response to infection (i.e. fever and tachycardia are normal responses to infection and therefore are, alone, not evidence of sepsis).

Sepsis 3.0

The quick SOFA score (qSOFA) also came out in hopes it “provides simple bedside criteria to identify adult patients with suspected infection who are likely to have poor outcomes.”  It is not part of the sepsis definition  but may help in identifying those that will die or have a 3 day ICU stay.  Studies looking at the performance of qSOFA applied retrospectively to data sets have not been promising [1,2].

Back Up Head Elevated Intubation

Khandelwal et al. Head-elevated Patient Positioning Decreases Complications of Emergent Tracheal Intubation in the Ward and Intensive Care Unit. Anesthesia and Analgesia. Apr 2016.

back up head elevated intubation

Ketorolac Dose

Motov, S, Yasavolian, M, Likourezos, A, et al. Comparison of Intravenous Ketorolac at Three Single-Dose Regimens for Treating Acute Pain in the Emergency Department. .Ann Emerg Med. 2016 Dec 16.

ketorolac

Pulmonary Embolism in Syncope 

Prandoni et al. Prevalence of Pulmonary Embolism among Patients Hospitalized for Syncope.   N Engl J Med 2016; 375:1524-1531. This trial is probably one of the most over-reacted to trials of 2016.  News outlets, both by lay media and for health professionals overstated the claims of this trial.

image

What the trial actually did…

PESIT

Out of Hospital Cardiac Arrest Prognostication

Jabre et al. Early Identification of Patients With Out-of-Hospital Cardiac Arrest With No Chance of Survival and Consideration for Organ Donation.   Intern Med. 2016 Dec 6;165(11):770-778

OHCA

ALTE (Apparent Life Threatening Event) is out, replaced with a new definition and classification, BRUE (Brief Resolved Unexplained Event).

Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B et al. Subcommittee on Apparent Life Threatening Events. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary.  Pediatrics. 2016

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References:

  1. Churpek MM, Snyder A, Han X et al. qSOFA, SIRS, and Early Warning Scores for Detecting Clinical Deterioration in Infected Patients Outside the ICU. Am J Respir Crit Care Med. 2016. [article]
  2. Brabrand M, Havshøj U, Graham CA. Validation of the qSOFA score for identification of septic patients: A retrospective study. European Journal of Internal Medicine. 36:e35-e36. 2016. [article]

Vaccine Side Effects and Placebos

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We are in Las Vegas at ACEP 2016 thanks to Annals of Emergency Medicine and ACEPNOW and discuss high yield or cutting edge lectures each day.

Dr. Matthew DeLaney – 21st Century Snake Oil (Placebos)

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SGEM http://thesgem.com/2013/03/sgem26-honey-honey/

Dr. Al Sachetti – Immunization Reactions in the Emergency Department

check out the WHO fact sheets

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Dr. Corey Slovis – Atrial Fibrillation

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References:

  1. Llor C, Moragas A, Bayona C. Efficacy of anti-inflammatory or antibiotic treatment in patients with non-complicated acute bronchitis and discoloured sputum: randomised placebo controlled trial. BMJ (Clinical research ed.). 347:f5762. 2013. [pubmed]
  2.  Smith et al. Over-the-counter (OTC) medications for acute cough in children and adults in ambulatory settings. Cochrane Database of Systematic Reviews 2012, Issue 8. Art. No.: CD001831. DOI: 10.1002/14651858.CD001831.pub4.22895922
  3. Dobson R. Cough medicines’ effect is mainly placebo. BMJ. 2006 Jan 7; 332(7532): 8. PMCID: PMC1325161
  4. Cohen et al. Effect of Honey on Nocturnal Cough and Sleep Quality: A Double-blind, Randomized, Placebo-Controlled Study Pediatrics; originally published online August 6, 2012; PMID:22869830
  5. Egerton-Warburton D, Meek R, Mee MJ, Braitberg G. Antiemetic use for nausea and vomiting in adult emergency department patients: randomized controlled trial comparing ondansetron, metoclopramide, and placebo. Annals of emergency medicine. 64(5):526-532.e1. 2014. [pubmed]
  6. Furyk JS, Meek RA, Egerton-Warburton D. Drugs for the treatment of nausea and vomiting in adults in the emergency department setting. The Cochrane database of systematic reviews. 2015. [pubmed]
  7. Beadle KL, Helbling AR, Love SL, April MD, Hunter CJ. Isopropyl Alcohol Nasal Inhalation for Nausea in the Emergency Department: A Randomized Controlled Trial. Annals of emergency medicine. 68(1):1-9.e1. 2016. [pubmed]
  8.  Friedman BW, Dym AA, Davitt M. Naproxen With Cyclobenzaprine, Oxycodone/Acetaminophen, or Placebo for Treating Acute Low Back Pain: A Randomized Clinical Trial. JAMA. 314(15):1572-80. 2015. [pubmed]
  9. Derry S, Conaghan P, Da Silva JA, Wiffen PJ, Moore RA. Topical NSAIDs for chronic musculoskeletal pain in adults. The Cochrane database of systematic reviews. 4:CD007400. 2016. [pubmed]
  10. Silberban. Placebos Are Getting More Effective. Drugmakers Are Desperate to Know Why.

The Transgender Patient + more from ACEP

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We are in Las Vegas at ACEP 2016 and discuss high yield or cutting edge lectures each day.

Dr. Anne Daul – Emergency Care of the Transgender Patient

Most emergency medicine physicians and trainees lack training in caring for LGBTQ patients, let alone transgender patients [1].  Many members of the LGBTQ community may have delays in medical care including 21% of transgender patients in a Canadian survey[2].  Also, according to a 2010 task force, 19% of transgender patients report being denied care in some way [3].

@FOAMpodcast
@FOAMpodcast

Here is a video from SMACC Dublin from Thom O’Neill on caring for LGBT youth

Check out these FOAM resources from EPMonthly and Mayo.

Dr. David Callaway – Active Shooter

2% of active shooter events take place in the health care setting.

Plan of Action in Active Shooter Scenario: AVOID DENY DEFEND TREAT

  • Avoid – stay away from the shooter.
  • Deny – deny them access to you or the area. Lock doors, block pathways, turn off the lights, make it more difficult for them.
  • Defend -.if necessary, defend yourself.
  • Treat – once you are safe, and the scene is safe, treat and care for your patients.

Dr. Kevin Klaur – Lawsuits

Documentation and discharge instructions repeatedly come up in lawsuits.

  • Documentation: If you document after the fact, particularly if there was a bad outcome – be straightforward that you are documenting after the fact. Do not document as though you do now know the outcome
  • Discharge – lawsuits often come up because discharge instructions or documentation were not sufficient. Klauer argues that it is not sufficient to state “patient improved, discharged home.” He urges us to document a repeat exam or show HOW they are improved.

Dr. Klauer also gave some general pearls on lawsuits – high numbers for orthopedics/missed fractures and administration of RhoGham.  An additional pearl he gave was for cauda equina.

  • These patients often have small post void residuals because it’s a neurogenic problem, not a mechanical obstruction.  Thus, if a patient has other features and has a post void residual of 100 cc, it’s not necessarily not cauda equina.

 

One ACEP16 lecturer talked about magnesium use in alcohol withdrawal – probably not ready for prime time, Cochrane agrees  [4].

References:

  1. Moll J, Krieger P, Moreno-Walton L. The prevalence of lesbian, gay, bisexual, and transgender health education and training in emergency medicine residency programs: what do we know? Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 21(5):608-11. 2014. [pubmed]
  2. Bauer GR, Scheim AI, Deutsch MB, Massarella C. Reported emergency department avoidance, use, and experiences of transgender persons in Ontario, Canada: results from a respondent-driven sampling survey. Annals of emergency medicine. 63(6):713-20.e1. 2014. [pubmed]
  3. Grant JM, Mottet LA, Tanis JD et al. National Transgender Discrimination Survey Report on health and health care Findings of a Study by the National Center for Transgender Equality and the National Gay and Lesbian Task Force.  October 2010
  4. Tejani SM. Magnesium for the prevention or treatment of alcohol withdrawal syndrome in adults. June 2013

Just In Time – A FOAM Resource Review

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Just in time for the new interns, we review our favorite resources to use on shift.

Free Open Access Medical Education (FOAM) exists in forms that are suitable for self-study or function as resources and those that are easy to use resources to consult on shift, Just In Time (JIT) Resources.

Our Favorite Free JIT Resources

ResourceWhat It IsOther
fri-post_aliem-logoSuccinct synopsis of presentation, workup, and treatment of a cornucopia of conditions seen in EM.Available on AgileMD application for smart phones.
556e4d7ce3105bb0e4d12e92811346cfA free app for smart phones that combines resources such as ALiEM PV cards, WikEM, Pediatric EM Resources, and a Toxicology Reference for off-line reference. Also, searchable.Free but requires account set-up.
Screen-Shot-2014-03-13-at-11.38.04-PMQuick outline of classic presentations, differential diagnosis, and treatment of many disease processes.Very brief, mostly outline oriented. Wiki structure, so not always clear how evidence based information is.
imgres1 minute review of commonly performed ultrasounds in the ED including technique and diagnosis.Not comprehensive - see the Emergency Ultrasound iBook or watch the full episodes of Ultrasound Podcast for detailed tutorials.
EMRA-Students-2016-PPTWell done procedural videos from a variety of resources (NEJM, Weingart, Mellick, etc)
urlExcellent, free, online calculator for everything from imaging decision aids, to HEART score, to free water deficit.Free iOS app currently available (7/1/16), may be paid at some point.

FOAMcastini – The Aorta and No Analgesia Will #!&?% You Up

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We cover pearls from smaccDUB (Social Media and Critical Care Conference in Dublin, Ireland), Day 3. We are here thanks to the Rosh Review.

Dr. Scott Weingart – “Post-Intubation Sedation

  • Analgesia first. Try a hydromorphone 1mg push while you’re waiting for the fentanyl drip. The endotracheal tube is uncomfortable.
  • Minimize sedation. There’s this principle: eCASH: early Comfort using Analgesia, minimal Sedatives and maximal Humane care [1]. 
  • Sedation: go for dexmedetomidine if you have it (but it’s expensive) or propofol. This is supported by the Society of Critical Care Medicine (SCCM) Pain, Agitation, and Delirium guidelines [2].
  • Be careful with rocuronium.  The long duration of rocuronium means that you can’t assess for pain or discomfort so you must be responsible and get these

Dr. David Carr – “The Aorta Will #!&?% You Up”

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Dr. Kathleen Thomas – “Oh Sh**! They’re bombing the hospital!”

We should not need a website entitled STOPBOMBINGHOSPITALS.ORG but, unfortunately, over the past 4 years, 400 hospitals have been bombed. This passionate, wrenching talk is a “must see” and “must listen” when the free talks are released on the SMACC podcast over the course of the next year.

References

  1. Vincent J, Shehabi Y, Walsh TS et al. Comfort and patient-centred care without excessive sedation: the eCASH concept. Intensive Care Med. 42(6):962-971. 2016. [article]
  2. Barr J, Fraser GL, Puntillo K et al. Clinical Practice Guidelines for the Management of Pain, Agitation, and Delirium in Adult Patients in the Intensive Care Unit. Critical Care Medicine. 41(1):263-306. 2013. [article]
  3. Watt JM, Amini A, Traylor BR, Amini R, Sakles JC, Patanwala AE. Effect of paralytic type on time to post-intubation sedative use in the emergency department. Emergency medicine journal : EMJ. 30(11):893-5. 2013. [pubmed]
  4. Imamura H, Sekiguchi Y, Iwashita T et al. Painless Acute Aortic Dissection. Circ J. 75(1):59-66. 2011. [article]
  5. Diercks DB, et al. Clinical policy: critical issues in the evaluation and management of adult patients with suspected acute nontraumatic thoracic aortic dissection. Ann Emerg Med. 2015 Jan;65(1):32-42.e12. PMID: 25529153.
  6. Hagan PG, Nienaber CA, Isselbacher EM. The International Registry of Acute Aortic Dissection (IRAD): new insights into an old disease. JAMA. 283(7):897-903. 2000. [pubmed]

Episode 49 – The AAP BRUE (formerly ALTE) Guidelines

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The Free Open Access Medical Education (FOAM)

We review the American Academy of Pediatrics guideline on Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants.

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Note: Some have voiced concerns that these guidelines potentially downplay the event. The concern is that the yield of these workups and admissions may be low, but possibly worthwhile.  At FOAMcast, we are not qualified to critique these guidelines but there are helpful tables and charts in them to realize that these recommendations really are only for specific events and children AFTER thorough history and physical.

Generously Donated Rosh Review Question

A 6-week-old boy is brought to the emergency room because of cyanosis. He was sleeping comfortably in a supine position right after a feeding when he suddenly choked, became limp and lips turned blue. The mother witnessed the event and blew to the face of the boy. The whole episode lasted for about two minutes. EMS was called and upon arrival at the house, the boy was back to his usual self. At the ER, he boy has normal vital signs with normal physical examination findings.

A. Admit for cardiorespiratory monitoring

B. Discharge after reassuring the parents

C. Observe for four hours in the ER

D. Request for complete blood count

Answer

A. Admit for cardiorespiratory monitoring. The boy in the vignette had an apparent life-threatening event (ALTE) which is not a specific diagnosis but a description of an acute, unexpected episode that is frightening to the caretaker. ALTE includes one or more of the following features: apnea, color change (may be cyanotic, pallid, erythematous or plethoric), marked change in muscle tone (limpness or rigidity) and choking or gagging. A specific cause for ALTE can be identified in over one-half of patients after a careful history, physical examination, and appropriate laboratory evaluation. The remaining cases are considered idiopathic if no cause can be identified after a thorough assessment. Common etiologies for ALTE include gastroesophageal reflux, neurologic problems (such as seizures), and respiratory infection. The history of an ALTE must be taken seriously, even if the infant appears entirely well by the time he or she is evaluated. In-hospital observation with cardiorespiratory monitoring is indicated for infants whose initial evaluation suggests physiologic compromise. Hospital admission may provide important clinical information where additional episodes may be witnessed by medical personnel during the observation period. In addition, serious underlying medical conditions may become apparent.  Discharging the patient after reassuring the parents (B) and observing the patient for four hours in the ER (C) are not appropriate management strategies for the infant in the vignette who needs admission for cardiorespiratory monitoring. Requesting for complete blood count (D) is not routinely done in the evaluation of an ALTE and would not aid in the management for the infant in the vignette.

References:

Tieder JS, Bonkowsky JL, Etzel RA, Franklin WH, Gremse DA, Herman B et al. Subcommittee on Apparent Life Threatening Events. Brief Resolved Unexplained Events (Formerly Apparent Life-Threatening Events) and Evaluation of Lower-Risk Infants: Executive Summary.  Pediatrics. In Press

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