EMU Monthly – January 2006

1) 192,136 patients in a metaanalysis showed that people taking lower than 100 mg of aspirin (average 81mg) had much less bleeding than those taking more than 100 a day. This included minor bleeding as well, and any bleeding at the time of the studies but it still may be a useful study. It may give us some thoughts about optimal discharge dosages on those patients that may have slightly higher risk for bleeding such as smokers. Seems the optimal dose is about 80 mg. (AJC 15 May 05) In the same issue of the AJC they studied therapy for patients over the age of 89 with acute MI. They do terribly with TPA, and do just as well whether you do cardiac catheterization or not. Obviously they did not reach a great sample size, but it does make me feel a little better when I do an EKG that shows an infarction and no one wants to touch the patient.

2) A rare article that could only be published in the MJA. This article bewails the demise of the physical exam. No one has ever done any studies to show it impacts patient care.   Even the US Preventive Task Force could find no evidence that periodic physical exam of the breast, heart, prostate or any thing else for that matter is beneficial. (MJA 18 Apr 05)While it is true that Babinski reflexes, or a heart exam in a patient with pericarditis or endocarditis can be very informative, I was at a lost this week when I approached the cardiologist for an echo on a patient with an MVR and an AVR in CHF to see if they have a leaky valve. They felt I should have been able to tell via exam of the murmurs.   By the way , it was the same journal in 2002 that said we only do the physical exam to impress patients, in essence it does not help us in most cases. Now I am sure this will raise some controversy, and it did in the MJA, but it just shows where medicine has come to.

3) We discussed Heparin Induced Thrombocytopenia last issue and we now have an excellent review of the subject (Circ 24 May 05) This disease can be occult- it can be seen many days after the cessation of heparin with a routine blood test showing thrombocytopenia or there may be a thrombus somewhere which clues you in. They do not usually present as bleeders. Problem is, you can not use coumadin, LWMH or heparin.

4) Does sputum color help in COPD ers. Yes- Yellow to brown is more likely gram negatives, and only 5% of purulent sputum failed to grow. (Resp Med Jun 05) Now the question is- is this growth colonization or the real thing?

5) They looked at my home state (Pennsylvania) which has no tort reform and saw that in 5 specialties (Ob/gyn, ortho, EM, surg and neurosurg) that almost half the practitioners said they did unnecessary tests and called unnecessary consults or passed patients who looked litiginous to other doctors. (JAMA 1 Jun 05) While in Israel , there are fewer frivolous law suits , still, there are more and more malpractice claims as people adopt the American idea that if someone died, someone has to be blamed.

6) Weird article, and I do not know how useful it is, but there are some agents that block potassium channels in the cell and as a result, drugs like noradrenalin will not work to get their blood pressure up (Lancet 28 May 05) They had success with getting blood pressures up in hypotensive patients with Glibetic as this opens these channels. Now one of the drugs that causes closing of channels is cylcoporine. Again, I do not see where this will help your practice, but if you have a patient in shock and noradrenalin does not help, at least you may know why.

7) OK remember, patients with PE due to DVT, you   need to keep them at bedrest so as not to dislodge more clot. Did they tell you that? Did you believe them? Bedrest, as we reported in the past is treacherous for just about everything (see Lancet 9 Oct 99) and it really does not help at all for folks with PE. (Chest May 05) In Israel we see a lot of erysipelas, and we tell them to rest as well- no evidence for this one either!

8) A lot of us read the Annals of EM, so I will not spend a lot of time here. In the June issue, they had a letter where they did femoral nerve blocks in hip fractures with good results. (June 05) This is good news, because an early study using the 3 in 1 femoral block was hard to perform and my experience was that it did not work. However there were few patients. Should you wish to try this remember the NAVL mnomic. Another study in the Annals showed taxi drivers only wore seatbelts 6.8% of the time despite the law saying they had to. Any idea what it is like in Israel?

9) You do not see articles like this too often, so make a note. What should you do for patients with an intrarterial injection that was done by mistake? Not always so clear what the pathophysiology is but try papaverine, or lidocaine for spasm, and perhaps heparin and fluids to prevent clotting (Mayo June 05)

10) If you get glue in the patients eye do not worry, this is what eye doctors use for some of their surgeries anyhow. What if it is swallowed- seems by this case report that this is no problem either- even though cyanoacrylate has cyanide in it, it is too tightly bound to be absorbed. (Int J Per Otolaryn Jun 05)

11) Last month we discussed the American College of Toxicologists Position Statement that charcoal should only be used for the first hour after an ingestion. There was an accompanying editorial that question this stating there have only been three studies of charcoal and they were all of poor quality. (Clin Tox May 05) So while there is no evidence that it does work, there is no evidence that it doesn’t work. What do we know about charcoal? It absorbs substances well in vitro, it does not absorb cyanide, hydrocarbons, ethanol, metals, ions, caustics, alcohols or lithium (CHEMICAL), it may have a second pass effect, it may discharge what it absorbs in the small intestine. Tox readers- any more input?

 

EMU LOOKS AT : Acute Porphyria

Alright, stop moaning- it is not the most glamorous of topics. But it is out there, and an emergency physician needs to know about it- from an emergency physician standpoint. This review was extracted from an article in the Annals of Internal Medicine, 15 Mar 05.

1) This is a disease of heme synthesis that can have acute life threatening attacks. It is an autosomal dominant disease. It comes in four flavors, but the one you have to know about it AIP or acute intermittent porphyria.

2) There are many clinical manifestations- here are the common ones.

a) Abdominal pain- usually with a silent abdomen, which gives an impression of conversion disorder. May have vomiting, but no peritoneal signs, no fever, no leukocytosis. They look like they are suffering

b) Pain in other places- extremities, head, chest- this is especially difficult to deal with, due- like the abdomen to a neurological origin. There may be muscle weakness and paresis. This can look like heavy metal poisoning or multiple sclerosis, or again like they are faking it.

c) Heart- tachycardia is common

d) electrolytes- hyponatremia is particularly common

Failure to treat in a timely fashion can result in long term sequalae

3) So what will make you suspect you are dealing with this disease? Dark or red urine, hypertension, proximal muscle weakness, or other strange neuro sympthoms, dieting (see below). Since there are many asymptomatic carriers, family history may not help you.

4) Triggers can help you. Medications can set off an acute attack (steroids, hormones, anticonvulsants) . Careful- in pregnancy- metoclopramide ( Pramin, Reglan) can set off an acute attack, while promethizine (phenergan) is safe. Other stressors- crash dieting, smoking, stress, alcohol) Many meds can cause an attack- the patient should come to the ED with a list or you can look it up on the internet.

5)Treatment: Of course stop using the offending drug. Some studies show the use of carbohydrates IV (in the form of glucose) will help- just be careful because large amounts will result in hyponatremia. Hemin is the treatment of choice and will reverse attacks. It is safe in pregnancy

Failure to treat can result in permanent neurological sequalae including respiratory paralysis

PLEASE READ THIS:

EMU has been giving this monthly service for many years now and needs some volunteers. We need one more peer reviewer to ensure that EMU stays at a high level to better help you ( Pinny Halperin, Mike Drescher and Moshe Weizberg have done a phenomenal job in this department for the last year)

EMU would also like to invite some of you who are computer geeks to give us a smoother and classier format- the old one is getting- well- old. And by the way, if you are wondering- the picture at the top is an emu.

Till next month…

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