EMU Monthly – August 2016

  • Hey it is August guys- the heat, the beach, summer camp with pimply counselors, and arts and crafts (I remember camp well – I was the goalie for Archery practice). Lacerations are a big part of summer and we have championed the intrathecal volar nerve block – but it is in an area full of nerves. So maybe do the dorsal two injection technique – but that has two sticks. This study found they both hurt at the same rate. But I am still in awe of these Aussies- both techniques failed more than 25% of the time. And pain scores of eight were still present five minutes after the injection. What were these guys doing?? Chris? (Emrg Med Austr 28(2)193) The one shot technique is the one I do and it is really easy – shoot in the middle of the base of the finger and when you hit the tendon – you won’t be able to inject- with draw a millimeter and inject. TBTR: Digital nerve blocks for chronic nose pickers.
  • Are you a woman? (we’ll give you a few minutes to figure that one out) Are you older? (we’ll give you a few more minutes to think about that one) Are you in poor general health? If you are given tranexamic acid you have more of a possibility of getting a seizure. For some reason this happens more often in post cardiac surgery patients. This may occur from inhibition of glycine. (Ann Neuro 79(1)18) I have never seen this, but they say it occurs up to 7.3% in post cardiac surgery patients. I would surmise however, that topical use for nose bleeds and the like and low doses in healthy people are fine TBTR: Seizures can come from using Tranexamic acid.
  • Ten myths in UTIs: this was already featured in MEDSCAPE and indeed there is nothing new here for those who read EMU religiously (am I nuts to think anyone does?) but get this article for your FPs (JEM 51(1)25) I just wanted it to be in our data base. And it is time for quotes: We at EMU never want to be accused of being politically correct, so let’s hit you guys with ridiculous Trump and Clinton quotes. First the Trumpster:“An ‘extremely credible source’ has called my office and told me that Barack Obama’s birth certificate is a fraud“Ariana Huffington is unattractive, both inside and out. I fully understand why her former husband left her for a man – he made a good decision.”
  • The moment you have been waiting aug-image-1for. Yes it’s our ketamine moment – a chance to sit back, relax and disassociate. (This is going too far back for most of our readers- but the association was a musical group responsible for the big hit “Windy” –I’m sure you all have heard it- “whose walking down the street of the city..” It was actually written reported to be about a male hippy- but Ruthann Friedman denies that rumor- she wrote the song)  There are some case reports out there thaaug-image-2t you can use this drug for prolonged sedation of children such as those in the ICU, those with opioid withdrawal, those with bronchospasm, or if they are having a prolonged temper tantrum (Ann Pharm 50(3) 234) TBTR:Ketamine IVCD- -silly, ketamine is for kidsaug-image-3

All of the women on The Apprentice flirted with me – consciously or unconsciously. That’s to be expected.”

“One of they key problems today is that politics is such a disgrace. Good people don’t go into government.”

  • We have two natural medicine articles for you this month- there are some places with limited health care resources nevertheless scabies doesn’t discriminate- they are free to for the asking. The common treatments – Ivermectin and Permethrin – are showing some resistance, so maybe try Tea Tree oil – it kills the buggers, and is anti-pruritic, and anti-bacterial as well. (Am J Trop Med Hyg 24(2)258) I am fine with that, but there is still no good evidence. Fu Zi is derived from Aconitum Carmicheaeli and is used as analgesic. It put this patient into VT. The authors of this case report that here was no safety information given to the patient (she took a large dose apparently), no notation on how the active ingredients were extracted (are there adulterants? Were the milligrams of the medicine weighed accurately?) This seems to be a problem with a lot of natural medications, and as I say to the patients –Natural doesn’t mean safe.(Can J Card 32:291) TBTR: Natural medicines – one may work, one may not safe.“It’s freezing and snowing in New York – we need global warming!”“I think the only difference between me and the other candidates is that I’m more honest and my women are more beautiful.”
  • Cyclic vomiting syndrome –with pregnancy – well, doesn’t that sound sweet? What works here? They say amitriptyline did the trick, and indeed I checked and it is category C in pregnancy. (Ob Gyn 125(6)1487) Now this could be because CVS has a brain gut connection, it could also be that this med has anticholinergic effects. However, there may be a psychological cause to CVS and that may be the reason this works. I am not sure how they concluded that this wasn’t Hyperemesis Gravadarum. TBTR: Cyclic vomiting syndrome with pregnancy – what would you to use?”The point is, you can never be too greedy.””My IQ is one of the highest — and you all know it! Please don’t feel so stupid or insecure; it’s not your fault.”
  • This is somewhat maverick  – aug-image-4but we like to be modern here. Appendicitis – maybe the surgery can be done ambulatory? They made a score here to help make this decision (Ann Surg 262(6)1167) but the study is retrospective, and they have a heavy dependence on blood tests. They did – to their credit – do imaging, but perhaps the ones that were eligible for ambulatory surgery didn’t need surgery ion the first place-? Too many questions but perhaps the futureaug-image-5

( this is  going back to the sixties also but click here for info on this film) TBTR: Ambulatory surgery for appendicitis?





“I was down there, and I watched our police and our firemen, down on 7-Eleven, down at the World Trade Center, right after it came down

“Number one, I have great respect for women. I was the one that really broke the glass ceiling on behalf of women, more than anybody in the construction industry.”

  • Fever on and off and ear pain for 10 days in an autistic child. They did a CT and found a Bezold abscess, sinus vein thrombosis, mastoiditis, and an epidural abscess. (JAMA Oto Head Neck Surg 142(1)95) OK, this raises a question – we all know that otitis media is a viral disease, and antibiotics are usually not required – but sometimes they are – and a miss can be serious. There are guidelines out there (these are the AAP but there are Danish, Japanese, Israeli – all recent). But I generally will not give antibiotics in garden variety but fever and a prolonged course or under one year old – I do give. Oh, and you say you do not know what a Bezold abscess is? Nearly got that one by you!! It is an abscess of the sterno cleido mastoid which forms by direct extension from the mastoid. TBTR: Ear infections – rare complications but be aware. You could see there was blood coming out of her eyes”The beauty of me is that I’m very rich.”
  • Boarding – we all hate this – but here is a new wrinkle – are you boarding psych patients? We all know psych beds are at a premium – and boarding takes a lot of manpower – but it still happens. The state of Washington Supreme Court has recently ruled that this practice is illegal. (Psych Serv 66(7)668) TBTR:

Boarding psych patients is against the law. aug-image-6

“If Hilary Clinton can’t satisfy her husband, what makes her think she can satisfy America?”

“Love him or hate him, Donald Trump is a man who is certain about what he wants and sets out to get it, no holds barred. Women find his power almost as much of a turn-on as his money.” (Trump on Trump.)

  • This is an article that is definitely a game changer and I would love to hear from Scott on it. There are new definitions for sepsis. The new definition is a 2 point increase in the SOFA score, hypotension unresponsive to fluids, the need for vasopressors to get SBP to at least 65(these patients are circling the drain in my opinion)  and – this is the curious one- Lactate greater than 2. On the positive side- SIRS is out. ( JAMA  315(8)757) The author of this editorial illustrates that the definition is still too broad – the treatment of an 18 year old and a 90 year old may still differ because sepsis is a spectrum. TBTR: – new definitions for sepsis.  And now some quotes from the Clinster”In my White House, we will know who wears the pantsuits.” –on the role her husband would play in her administration”Well, that hurts my feelings.” -on why voters like Barack Obama better
  • I didn’t want to mention this, but I still see too many folks who are confused – what is the definitive treatment for abscesses-do they need antibiotics or not? The answer is – it depends (isn’taug-image-7 it annoying that that is the answer to all questions in medicine  (- Howard the Duck – how is that for annoying?). Generally – and read the discussion in this article- they don’t. DM may, and MRSA seems to do better with antibiotics if there is a high prevalence in your area. (EJM 374(9)882. I would add also those who live on the street or (in my hospital) in the desert or have poor follow up probably will benefit as well. I routinely give to breast abscesses that I needle aspirate and peritonsillar abscesses. Olecranon abscesses- see last month’s essay. TBTR: Abscesses- should you use antibiotics?”I’m undaunted in my quest to amuse myself by constantly changing my hair.”If I didn’t kick his ass every day, he wouldn’t be worth anything.” –on Bill Clinton
  • Morphine is in trouble again. It is bade enough that it is aaug-image-8 member of the infamous opiate family and constantly chased by the narcs (Narcan) – but now it has run  into a DOO (disease oriented outcome)problem- Ticagrelor seems to work slower and weaker in patients who have gotten morphine for their MI. The authors admit you gotta give something- MIs do hurt- but we don’t know what that should be until further studies are done. I say – let us see some patient oriented outcomes that really matter. They also point out that while Morphine has some anti-sympathetic tone properties, there really is no role for it in acute pulmonary edema. There is some literature that people who received morphine in APE aug-image-9do worse. (Eur Heart J 37:253) I actually have become less of a morphine fan and more of a Fentanyl fan – thus avoiding all the problems of cumulative doses, changing doses in CRF, histamine releases and slow and fast metabolizers (although the problem with Ticagrelor- no info if it would still be a problem with Fentanyl). While we are talking, it is time for an eighties flashback – the author of this study was Atar, and that name is shared by two folks from back them – Crazy Eddie  –(some write it as Antar, but close enough) aug-image-10 those electronics stores whose” prices were insane” – all those stores are closed after the CEO was arrested and Pat Benatar aug-image-11(really she is an Atar – ben is a prefix that means son of) (Pat is really Polish, but Benatar is her ex-husband’s name)You have for sure heard her signature song – “Hit Me with Your Best Shot” TBTR: Morphine in MI – give it some thought before you do it.”I have said that I’m not running and I’m having a great time being pres — being a first-term senator.””We have a lot of kids who don’t know what work means. They think work is a four-letter word.”
  • This is a basic article but I still see a lot of flumazenil given wily nilly. The purpose of this article was to contrast Narcan and flumazenil- the former now given freely for use by non-medical personnel and the latter black boxed in the USA. It is true that Flumazenil is a problem in patients who then subsequently seize but the article points out – these patients usually have other high risk features that would lead you to be cautious. But the truth is, you don’t need to come on to this – benzo over dosages- unlike opioids that cause respiratory depressions centrally – cause respiratory effects by upper airway occlusion (this is based on a article from 2002 – seems hard to believe – but maybe) Therefore, intubation is more popular as treatment for a Benzo OD.  Flumazenil can have some use- it is the drug to use if you over sedated a patient; it also causes patients to awake if they have had sevoflurane, or propofol ( interesting – I was taught that if you gave Flumazenil and they start to seize –give them propofol- will it still work? You always have ketamine.) . It can reverse depression of diaphragm function in patients that were intubated, and it can treat paradoxical agitation that can occur with midazolam. Naloxone can be given IM, IV, nebulization or in the nose, but orally or by ET  aug-image-12tube are discouraged (I was always taught that ET  route can be used.) The dose has gone down lately – they say 40 micrograms is enough in most patients, but remember that both drugs wear off rather quickly.(BJCP 81(3)428) TBTR: Narcan and Flumazenil- the nitty gritty.”He ran a gas station down in St. Louis… No, Mahatma Gandhi was a great leader of the 20th century.”
  • We have been proponents of apneic oxygenation of patients pre intubation – this is: have a nasal cannula pumping in oxygen they whole time. However, they found no difference in disease oriented outcomes in patients who did not get this nor did they find any advantage over pre oxygenation (AJRCCM 193(3)230) Maybe, but you need a lot more than 15 liters per minute of oxygen to flow into the lungs (i.e. positive pressure) in in this study they only used 15. Furthermore, they ignore, that this allows us more time to intubate. TBTR: is apneic oxygenation out??  Now the other half of the Clinton team –Bill.”Being president is like running a cemetery: you’ve got a lot of people under you and nobody’s listening.””You know, if I were a single man, I might ask that mummy out. That’s a good-looking mummy.” (on seeing an Incan mummy)
  • Just a couple of dental articles- not because I have any love for Dr. Yankems- who does?- but if you are going to cause so much pain and suffering – you better have some literature to back yourself up. If there is no fever you do not need antibiotics for endodontic infections or pain – although they admit their EBM search showed only fair studies. I dunno; it always helped me. What about antibiotics after extractions? |(JADA 147(3)186) Here we have a Cochrane, but again the evidence isn’t great and most of it is on impacted wisdom teeth – which may be different than other extractions. In these extractions, their NNT is 12 for infection prevention and 38 to prevent dry socket. They also may reduce pain – but there is no NNT here. What about more infected extractions and folks with other illnesses? What seems to be clear is that you do not need them routinely, although a NNT of 12 is pretty impressive. (Cochrane CD00381) TBTR: Tooth fairy concerns.”What’s a man got to do to get in the top fifty?” –Bill Clinton, reacting to a survey of journalists that ranked the Monica Lewinsky scandal as the 53rd most significant story of the century”Sometimes I feel like the fire hydrant looking at a pack of dogs. For six years I had declined to tell those kinds of jokes, because I have been told it is not presidential. But I feel kind of outdoorsy today.” –Bill Clinton, at a party honoring the 150th anniversary of the Interior Department


Hey we all remember Oscar Madison from the Odd Couple aug-image-13His initials are OM so let’s get started with OME-Otitis Media with Effusion. The source for this essay is Oto Head Neck 154(2)201.

  • Not really an emergency problem but definitely an incidental-oma that we see a lot of. Just know that this is extremely common – 90% of kids under school age will have OME and they will develop 4 episodes of it per year. This can result from an URI, poor Eustachian tube function or as an inflammatory response to OM. Kids with Down syndrome and cleft palate have this problem even more so.
  • Why does this bother us? Because these kids may have hearing problems (my kids are big and have hearing problems also – or maybe it is just listening problems), balance problems poor school performance and recurrent OM.
  • Learn how to do pneumatic otoscopy- this is cheap and easy to do- but most docs do not know how to do it. Fear not, the article does have a nice table on how to do this properly and how to interpret it.
  • Tympanometry helps decide on whether this is really an effusion and what your chances of for spontaneous resolution. IT is more accurate and can also tell if there is a perforation. The article doesn’t tell you how to do this because you aren’t going to do it- you send them to a tech to do this study.
  • If you find OME and there are no school problems or hearing problems – just keep an eye on it.
  • No Steroids. Period. No antibiotics. Period. No antihistamines. No decongestants. Double period. aug-image-14
  • Smoking around the kid – if you are really that stupid -makes things worse. Have kids swallow when planes land to reduce pain – they can fly with an effusion.
  • Yes to hearing tests if they have an effusion that doesn’t go away.
  • If there is a persistent effusion and there are learning or hearing problems – under four have them get tubes, over four they recommend tubes and adenoidectomy. Tubes can have otitis problems- they should be treated with drops. They can go swimming with tubes (as long as the water is clean) and the tubes usually fall out in 12- 18 months. No mention about adults with OME – I spoke to my ENT and they suggest endoscopy toconfirm that there is no tumor. I know diuretics also do not work

Madison is also Addison with an M attached – so we now delve into that subject. Source here is the AJM 129(3) 339.

  • Well, Addison’s is the realm of the internists and as such there are – as usual going to be primary, secondary and glucocorticoid induced causes of adrenal crisis (yes, I know, glucocorticoid is a secondary cause, but go tell that to an internist). Primary causes include autoimmune, infections (TB, AIDS, and fungi), congenital, bilateral hemorrhage, or adrenalectomy (what a surprise). Secondary include any tumors or surgery affecting the pituitary, head trauma, Sheehan’s syndrome, and empty sella. Curiously, mets to the adrenals do occur, but insufficiency is rare unless the mets are bilateral and extensive Primary is the most serious and one most likely to lead to crisis but glucocorticoid suppression is the most common cause,
  • Here is the problem – crisis can be the first presentation in up to 50*of patients with Addison’s. Most of the time, the diagnosis is delayed since the progression may be slow and the symptoms nonspecific-fatigue, nausea, fever, lethargy etc. When crisis occurs, they have hypotensive shock and, altered sensorium and may have vomiting or diarrhea or abdominal pain which may lead to a mistaken diagnosis.
  • Hypotension: It may be due to hypovolemia or secondary to lack of catecholamine. The former may be treated with fluids, but the later may be refractory to fluids.
  • Hyponatremia occurs, and is due to either failures to suppress vasopressin leading to impaired free water excretion (this is in secondary adrenal crisis) or aldosterone deficiency in primary. If it is the latter you will see also hyperkalemia and volume depletion. Hypoglycemia and hypocalcemia may also occur in crisis.
  • Most of the time there is a precipitating event usually GI illness (due to impaired absorption of oral steroid treatment?). However, be aware that emotional stresses can also cause this problem -the literature includes such precipitants such as flight delays, wasp bites and reading EMU.
  • Do not forget occult sources of steroids that may cause adrenal suppression- inhaled, intra articular, Megesterol, Medroxyprogesterone, and use of anti fungals or ritonavir which inhibit the CYP3A metabolism network. P450 enzyme inhibitors can causethis too. DI, DM, and hypogonadism (oh boy, are you in trouble) can cause precipitate crises but the reason is unknown.
  • DO NOT BE AN INTERNIST when these patients come in – if they are unstable – treat them – if you have time you can take a serum cortisol and an ACTH and DHEA and renin and aldosterone, but do not waste precious time if they are in crisis. Fluids- here you do want normal saline – are given first and dextrose if they are in hypoglycemia. Careful with cortisol – it will correct the sodium – but you need to do this slowly so they do not develop osmotic demyelination syndrome. So do not correct the sodium more than 9 meq in the first twenty four hours- giving 100mg of Solucortef will usually be enough in the ED.
  • Prevention is debated hotly, because we are not really sure how much steroid people need daily and with stress. Since GI problems are the most common precipitating cause – they recommend early parenteral treatment. They recommend that a family member be trained to give the first steroid dose at home and not the patient – since patients are often altered. For other cases – major surgery, birth, and dental surgery – see the chart in the paper on how much steroid to supplement to prevent crisis.
  • I will give some steroid in shock that is not responding to fluids and pressors, because you never know.


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