EMU Monthly – December 2005

1)   One of my often claimed points in EM is individualization. It is easy to say that after 6 hours you increase infections rates in limbs that require suturing, but I think we all agree that a diabetic has much less than six hours, and a young kid with a healthy immune system probably has more than six hours. In a similar vein is the treatment of pneumonia. In a call for individualization, Niederman (CID Dec 04) feels that most pneumonias will reach clinical stabilization within three days in people. Those who have do not reach clinical stabilization will need more aggressive therapy, for at least ten days. Predictors of those who will not reach rapid clinical stability include Diabetics, virulent bacteria, etc. Clinical stability by the way means, HR less than 100, no fever, and SBP and sats greater than 90 (these last two, in my eyes, are still worrisome signs). This study of course says nothing about how many days anyone needs to be on antibiotics- but it is a start.

2)   Echinacea for the common cold- a structured review found poor studies, and in the only well done study, this stuff didn’t work. (CID 15 Mar 05) By the way, Vitamin C has been disproven as well (Natural Med Database, Prescribers Newsletter)

3)   A metaanalysis- proton pump inhibitor therapy in ulcer bleeding does not reduce mortality, but does reduce rebleeding and surgery. (BMJ 12 Mar 05) Of course, no one goes to surgery anymore for ulcers, and I am not sure why these folks are admitted to the surgery ward in Israel. Also note that H2 blockers have no acute role in GI bleeding, and IV proton pump inhibitors are as yet unavailable in Israel

4)   Did you know that tramadol + antidepressants is a bad marriage? If your patient is taking an SSRI – there is more chance of serotonin syndrome, if they are on tricyclics- there is more chance of seizures. (Pharmcoepid Drug Safety Mar 05) we are on the subject, NEJM(Dec 1 2005) gives the answer to a question we asked two months ago in EMU- indeed, all antipsychotics- not just atypicals- cause more mortality

5)   No IV access in an IVDA? Both IM and intranasal Narcan work, IM works about two minutes faster (MJA 3 Jan 05)

6)   We have spoken often about the fact that women often get poorer treatment for myocardial infarction (see JACC 15 Mar 05). Here are some other differences that will affect your practice. Women have more propensity to torsade, and QT lengthening, they have slower gastric emptying and a higher pH; they have different absorption characteristics –especially in subcutaneous therapy. Injections IM are more likely to be subcutaneous in females where absorption is worse and there is more subcutaneous tissue. They are also more susceptible to HIV (J Women’s Health Jan 05)

7)   OK, it was a small study, but Augmentin is extremely popular in Israel, and this study showed poorer cure rates clinically and in microcure rates when compared with cipro in UTIs (Postgrad Med Feb 05)

8)   Lots of things work for migraines, and this study once again showed that metoclopramide (Pramin, Reglan) worked as well as sumpatriptan (Imitrex) (Neuro 8 Feb 05). Phenothiazines probably work the best according to Jerry Hoffman; I have seen another study that stated that phenothiazines work better than metoclopramide but that neither work so well (AJEM May 96). In any case, whatever you use, remember that early treatment of migraines is the key (see also Ann Emerg Med Apr 05)

9)   Ultrasound can be tough for AAA detection in fat patients, and rupture can not be determined via ultrasound. However the addition of contrast seems to help, although the study only included 8 patients. Still, I find this very interesting (AJR Feb 05)

10)                  Do not forget heparin induced thrombocytopenia

which occurs 9-12 days after discontinuing heparin. It causes thrombocytopenia and thrombosis, and it will be made worse by given more heparin for these thromboses. Keep it in your differential for thrombocytopenia (Ann Emerg Med Apr 05)

 

11) Asymptomatic hematuria- in kids. If it is microscopic, you will not find much for your million-dollar workup (if there is no proteinuria and no hypertension). If it is gross, then you will need to advise workup if only to rule out Wilm’s tumor. (Arch Ped Adol Med Apr 05) Note this article was not in the setting of trauma- I have had this discussion often with our trauma guys- if there is microscopic hematuria, you may miss a pedicle tear of the kidney which may lead to kidney loss, but on the down side- there isn’t much you can do to save the kidney (Personal communication Dan Simon) However, kids do have less muscle mass covering the kidney, so you should be aggressive in imaging kids who have significant hematuria after trauma

 

12) So the toxicologist say that charcoal has never been proven to improve outcomes, despite reducing absorption by at least 25% if given within three hours. This is hard to swallow (no pun intended?) We have little else to offer, and we do know that charcoal absorbs. They recommend using it if it is within 1 hour (Clin Tox Feb 05) my personal experience is that charcoal can reduce paracetomol levels even if the amount taken is way over toxic dosages

 

 

EMU LOOKS AT: Diabetic Feet

 

This is a disease that spans many specialties- in Israel, this is a disease treated by internists, with involvement of ID specialist, orthopedists, vascular surgeons, rehab guys and “shikomists” (basically orthopedists who specialize in amputations). It is also a field that in Israel has attracted alternative medicine practitioners who promise miracles with various trade secret creams. While our literature ignores this entity, indeed this is a disease of emergency medicine as well. What follows is a review of the IDSA guidelines printed in CID 1 Oct 04 and a review of the subject written in IJEM, Oct ‏2005‏‏

The review will be from an EM perspective

1)   The first and most important point is that not all diabetic ulcers are infected, and even the infected ones do not all need hospitalization and intravenous antibiotics. That being said, there are many classifications but let us take the simplest. A wound that lacks signs of infection or purulence needs nothing other than routine wound care.

2)   A wound showing 2 signs of inflammation (purulence, erythema, pain, tenderness or induration, with no associated systemic illness, who has mild cellulitis (less than 2 cm) and is limited to the skin and subcutaneous tissue has a title of mild infection

3)   Same, but has in addition at least two of the following- more extensive cellulitis, red streaks, deep tissue abscess, gangrene, involvement of muscle or tendon or joint or bone- this is called a moderate infection. You may need to probe the foot to determine extent of infection

4)   Same, but in a patient with systemic toxicity or metabolic instability. Who is at risk for diabetic feet? Smokers, long duration of infection, obesity, elderly and insulin requiring diabetes.

5)   Mild infections will still be primarily beta hemolytic strep and staph. Infected ulcers will be the same pathogens provided the patient has not had antibiotics in the past. As such, cephalexin, or clinda suffice. Of note- feet with infection secondary to maceration as a result of soaking can grow pseudomonas and should receive treatment for this.

6)   Moderate infections are usually the same pathogens, however, if the patient has a chronic ulcer that has become reinfected, enterobacter must be considered as well as multiple species that can crop up if this is a long standing ulcer treated with numerous antibiotics. These folks are well systemically, so many can be managed with appropriate home care IV antibiotics, or in a long term care facility with IV Cefazolin or Vanco, or in people previously treated, IV Augmentin or Cipro + Clinda. In Israel, many of these folks will be admitted until social services can arrange home care. Really well looking patients can perhaps receive oral therapy. Anaerobic infections are actually unusual in this group. Of historical interest is that the first two reported cases of Vanco resistant staph came from people with diabetic feet. There may be some utility to topical antibiotics, but the evidence is not strong.

7)   These folks are septic. They have mixed flora and need the big guns- Imepenem, or Piperacillin-tazobactam.

8)   Who needs surgery? The obvious signs are of course gas gangrene, necrotizing fasciitis, or critical ischemia.   But if there is appropriate care, and infection persists, it is time to involve them as well. Dry gangrene? Let it fall by itself. Eschar? If it is not infected, leave it until soft enough to remove. Bypass can still be an option as vessels below the knee and below the ankle tend to be spared.

9)   Patient for discharge? Inform him to keep pressure away from ulcerated areas and ensure a dressing that encourages a moist environment with the ability for daily inspection

10)                  While less relevant to us, surgical solutions to osteo – such as amputation may cause changes in the structure of the leg leading to more ulcers, while nonsurgical treatment of osteo has a 60-80% healing rate.

11)                  HBO works- maybe.

Happy New Years to my American readers, and a happy Sylvester to my Russian readers.

 

 

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