EMU Monthly – October 2016

  • Been waiting for this one- and I guess it is time to remember Dr. R- she was a foul tempered surgical resident, had been married a few oct-image-1times, chain smoked and who didn’t enjoy trauma. If someone came in after being kissed by a fender or being run over by a steamroller – they got the same work up – total body CT. Then I started working in this huge trauma center, and sure enough – total body CT. Well we can all rest easier now. This four-center international study showed that outcomes were the same in both groups.  (Lancet 388:673) Does sound convincing but the fact is that in the selective group 46% still got a head to pelvis scan – making this a lot less helpful. TBTR: Selective versus total body CT- – outcomes are the same in trauma. (Lancet
  • This is a return call to give metoprolol in a renewed effort to push beta blockers to the forefront again.   Now they point out oct-image-2

that most studies that questioned this practice were done before the age of fibrinolytics. It could be true that these do limit infarct size but we need a good study to prove it- not a post hoc analysis that they bring. Is it better than Effient and Brillinta? When combined with those, is there a synergistic effect? That is the info we really need to know. JACC 67(18)2105

TBTR: Metoprolol – is it back for MI?

  • Do transfusions cause more mortality? Go ahead, I challenge you – prove it. Usually the studies that show increased mortality are in patients that are real sick anyhow – so how can you tell? So this study says that it doesn’t in patients with renal failure who are receiving renal replacement therapy.  But the kicker is that this was shown in patients who were in the ICU – where they got maximal therapy- and only in those who survived five days. TBTR: RBC transfusions – more mortality? Maybe not. CCM 44(5)1014)

Quotes this month come from a site I discovered accidentally. Witty quotes from wise women.

I always wanted to be someone; I should have been more specific. – Lily Tomlin

Deep down, I am pretty superficial –Ava Gardner

  • Our Ministry of Health- which carries a lot of weight here- makes our nurses ask the pain scale – you know- rate your pain on a scale of one to ten. Everyone here always says ten. I think that Joint Commission also requires this. I think we must be sensitive to pain but I also think this scale is asinine. This article – which really should be read by all of you – makes it clear that this is a possible cause of the opioid epidemic, it doesn’t check the patients desire for analgesics, it cannot take into account other factors which make contribute to the pain (i.e. like anxiety) and it makes us look bad (“Your Honor, it is clear that  they did not take the plaintiff’s pain seriously”) (Ann Emerg  Med 67(5)573) This was written by pain gurus Steve Green and Baruch Krauss and I can’t added anything – this is a true bulls eye. TBTR: Pain scales pain me.

I am not offended by all the dumb blond jokes because I know I am not dumb- and I also know I am not blond either. Dolly Parton

I don’t have the time every day to put on makeup- I need that time to clean my rifle.  Henrietta Mantel

I refuse to look at them as chin hairs – I think of them as stray eyebrows Janette Barber

  • Yea I am biased. This is an Israeli study. However, it is on a subject many of us are weak on. Adnexal torsion. They sought to compare the presentation of paediatric, adolescent and reproductive age women aoct-image-3nd found that actually, the presentation was pretty similar. However, the younger women –girls and adolescents – usually waited before presenting for care. Also the causes for the torsion differed although this is less relevant to our practice. All the causes though- can recur. (J Women Health 25(4)391) TBTR: Adnexal torsion. Don’t miss it. Can you imagine a world without men? No crime and lots of  happy fat women   Nicole Hollander.
  • Ever hear “it’s all natural” meaning it has to be safe. Well, there is actually a database for adverse drug reactions called VigiBase and it is run by the WHO and yes; you can access it. Allergies seem to be the most common side effect- something very common for you Aloe Vera aficionados. (Drug Safety 39(5)455)TBTR: Natural medicines- safety??

Who ever dreamt up the word mammogram? Every time I hear that, I think I am supposed to put my blood in an envelope and mail it to someone.  Jan King

  • I usually do not bring Annals articles because many of you read oct-image-4them, but you all know how much I like lactate (oh c’mon, we’re just friends  We know that according to the new sepsis guidelines – which I reviewed last month- above three is serious. What about between 2-3? If the patient looks infected- this could have serious repercussions- begin therapy with antibiotics and fluids. (Ann Emerg Med 67(5)643) TBTR: Lactate. Love it or treat it.

We have women in the military but they don’t put us on the front lines. They don’t know if we can fight; if we can kill.  I think we can. All the general has to do is walk over to the women soldiers and say “you see the enemy over there? They say you look fat in your uniforms”  Elayne Boosler

  • This is a JAMA study – how could I criticize it? I am truly not worthy, but I think the point is important. Giving electrolyte fluid in minor gastroenteritis is barbaric – the stuff tastes so icky. Why not give them what they want to drink? And indeed more children continued with the therapy when this happened. (JAMA 315(18)1966) The problem is – all children had to have diluted apple juice/proffered fluids first if they were in the group that got to drink what they wanted.  Then they got to drink afterwards according to institutional protocol. That really isn’t giving kids what they want to drink That is another problem – most kids with AGE don’t go to the tertiary ED. TBTR: kids – give them what they want to drink.

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There are three ways to get something done. Do it yourself, employ someone or forbid your children to do it.  Monta Crane

  • We all know this, but here is an article to wave in front of your kidney docs – which is what I did. Kexylate can cause colonic necrosis – – and it is not that rare (0.4% in their series).It can also cause hypernatremia and hypokalemia, but I can’t really say how often this occurs since they called hypernatremia greater than 145 and hypokalemia less than 3.5- clinically speaking that may not be significant. (Clin Neph 85(1)38).So what should you use? Well, dialysis is a good idea after you have used the initial therapies and I like furosemide. TBTR: Sodium Polystyrene – time for an alternative?

Success didn’t spoil me, I have always been insufferable.  Fran Leibowitz

  • Big time literature search which tries to help us treat cardiovascular toxicity due to cocaine. Benzos- can help but not always. Calcium channel blockers can reduce hypertension and vasospasm, but not necessarily tachycardia. Nitroglycerin can cause sever hypotension and reflex tachycardia . Alpha one blockers – same as calcium channel blockers – but much less evidence. Beta blockers- we were taught these are really bad because of unopposed alpha stimulation –the evidence shows it could be correct – go to labetolol or carvedilol but be aware that the alpha blocking is not as strong as the beta blockade. Antipsychotics- will help with agitation but not consistently with tachycardia or hypertension. EPS can result. Morphine deals with coronary vasospasm, but not tachycardia. Basically, the evidence ain’t great, but there is some guidance. (Clin Tox54(5)345) TBTR: Cocaine chest pain- some guidance.

I am furious at the women’s libbers.  They get on soapboxes proclaiming how women are smarter than men.  That’s true but it should be kept quiet or it will ruin the whole racket.  Anita Loos

  • We really do not give injections IM as much as we did in the past, but I learned from Nurse Mary how to give a painless shot- give the skin a nice pinch and inject- they feel the pinch but not the injection. Here they checked three techniques – all of them reduced pain but I do not buy that internally rotating the foot will help. The Z technique may be worthwhile. Here is a picture of how it works.  (Int J Nurs Pract 22(2)152) TBTR: IM injections- how to, not why.

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Dear, never forget one little thing- this I my business; you just work here  Elizabeth Arden to her husband

  • I guess there may be some relevance to this article to EM. They claim that if you take sign-out in written form during change of shift the information on the paper won’t stay current for very long- half of the patients will have inaccurate information within six hours (BMJ Qual Saf 25(5)324). I imagine that in many pales electronic or easier to update smart phones should have replaced written sign out but I guess people may not update those also. TBTR: Sign-out blues.

Women’s rule of thumb- if it has testicles or tires- it is only going to cause trouble – Anon ( I imagine a female said this)

  • Type one and Type two errors- I read a lot of articles on statistics, but I think this is one of the clearer ones. The one thing I liked with this article – other than it was short- is that it didn’t use any examples- the articles that do are so confusing. The article will define these errors to you – which basically is whether the null hypothesis was accepted or rejected in error. In this is the definition of p value – which is the amount of error we find acceptable in making our conclusion (i.e. if we accept the results as true- a p value of 0.05 means we still have a 5 % chance of being wrong.) What you need as a reader of the literature  is to know that type one error is increased if multiple endpoints are  investigated, there is a secondary analysis of the data (what Prof Hoffman – “Jerry” calls data snooping or data torturing), interim analysis of the data and stopping trials early. Type two errors – or beta error is due to an improperly powered study. Power is defined but that part was confusing to me but sample size is a big part of this. It also depends on whether the clinically relevant difference is going to be big or little. TBTR: A little statistics – it won’t hurt. Acta Paed 105:605

If they can put a man on the moon, why can’t they put them all there? Anon

  • Dental avulsions- most commonly affect the incisors, but we have written on this subject in the past. Here are some pointers-(pun intended? What pun?) – but remember these are dentists whose dedication to EBM is not the strongest.(“what they hell do I care what the evidence says? As long as I get to use my drill and it hurts…”). Even if the root remains (I assume they mean one or two of the roots) you can still reimplant. For them, milk is the ideal solution for preserving teeth if you can not reimplant them. In adults, the rate of avulsion is less as they more frequently fracture. By age 10-11; blood flow at least to the incisors is reduced and these teeth often need root canal if re implanted. They like tetracycline for antibiotic coverage (although in the “how to reimplant section they say amoxicillin) but they give no evidence why we need antibiotics in the first place BMJ i1394

TBTR: Teeth that have avulsed are not like pulling teeth.

Men- can’t live with them, can sell them for parts  -Cheers

EMU LOOKS AT: DRUGS

Yes a golden opportunity to slow that heart rate, take care of your pains, and even smooth out your blood. We are of course speaking about Acetaminoamiodonoac. ?????? The sources for these essays are listed below

TAKING CARE OF PAIN

J Palliative Care 19(2)231

1) I dunno, they say IV acetaminophen is really expensive, but in Israel – at my shop- it goes for four dollars a treatment which isn’t terrible.

2) This med has higher concentrations in the CSF. It also works faster while having the same duration of action as po. However, how this translate into patient oriented outcomes is questionable- there have been some studies that saw no difference in overall pain control with IV.

3) IV has less chance for liver toxicity but in malnutrition or iatrogenic causes (i.e. – your doctor was an idiot) – it can occur. The Rumack Matthew nomogram does not work for IV.

4) This was not in the article but we have written in the past of the poor absorption by the rectal route of this medication in general.

SLOWING THAT HEART RATE

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AJM 129:468

  • Your either hate it or love it. I am speaking about amiodarone. And I hate it.
  • One study showed an almost 20% reduction in mortality in high risk LV dysfunction patients. Another study showed no effect on survival but up to five fold increases in pulmonary and thyroid toxicity.
  • AED are much better for VT but Amiodarone + beta blockade can reduce the frequency of shocks.
  • It is used for A fib, but was actually never FDA approved for this use. The drug has a long half life and a huge volume of distribution and as such can take days to weeks to reach effective levels. IV increases levels rapidly but it can still take a few days to suppress arrhythmias. By mouth it can keep 65% of a fibbers in sinus rhythm over a year. This doesn’t sound great but then again-sotalol and propafenone are only 37% effective. By IV – in one study- only 5.2% converted to sinus.
  • IV is the way ACLS wants you to give this drug but while it does increase survival in shock resistant VT it does not lead to more discharges alive from the hospital.
  • Oh, those side effects. They can occur 15% of the time in the first year, and up to 50% during long term use. Fatigue (hypothyroidism, or bradycardia or even AV block), cough  (pulmonary toxicity), syncope, skin changes (photosensitivity), weight loss (hyperthyroidism), weakness or parasthesia (neuropathy) AEDs may not detect the slow VT that can happen with this drug and it may take more energy to defibrillate.
  • Drug interactions – you name it-dig, qunidine, warfarin,procanamie, dilt and verapamil, beta blockers, flecanide, phenytoin, cyclosporine, statins, and anesthesia.
  • When it does cause trouble – it stays around for a while – with pulmonary toxicity – it will respond to steroids but you need to take them for a long time. Thyroid? You may not see frank thyrotoxicosis since the beta blocking effects of amiodarone block these. But hypothyroidism is more common. You will need prednisone and an anti thyroid drug here. Did hyperthyroidism cause a patient’s a fib? Careful using amiodarone!
  • Liver toxicity occurs and can stay around a while but usually resolves when the drug after the drug is stopped. Poly neuropathy may occur and this may not get better with discontinuation of the drug.

SMOOTH OUT YOUR BLOOD

J Vasc Surg 63(6)1653

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  • You knew it was coming – you just did- we will speak about NOACS. I hated these also- but I have started to appreciate the beauty of these drugs
  • Let’s get the names straight and what they are approved for as of press time. Pradaxa(Dabigatran)- the oldest one- is approved for Afib stroke prevention, treatment of DVT and PE, and prevention of VTE. No useto in hepatic or renal populations. It cannot be used in nursing or pregnancy. Under 60 kg- it can be used. APTT may be increased by 1.5-1.8. It needs to be taken twice a day generally and has an antidote. It intereacts with rifampicin and ketocaonazole.
  • Xarelto (Rivaroxiban) is approved for all of the above and in CAD as well. Everything we wrote about Pradaxa above applies here other than there is no antidote and that it is given once a day. It interacts with carbamazepine, phenytoin,rifampicin, HIV protease inhibitors, itra and keto conazole. Also clrarithromycin.
  • Elquis is apixaban and is approved like Pradaxa. Also given twice a day. Don’t give in renal impairment or in hepatic impairment or in weights less than 60 kg. Same interactions as Xarelto. Given twice a day. APTT is barely elevated but PT does by two fold.
  • Lixiana is the new kid on the block and is given once a day. It is only approved for stroke prevention in afib and DVT/PE treatment. Can’t be used in hepatic or renal failure or in less than 60 kg unless you reduce the dose. Has all the interactions of the above plus verapamil, and quinidine and dronedarone. APTT barely moves, but PT does.
  • So what do I use? Xarelto is easy ot dose and has about the same interactions as the others. But I change my mind quickly.

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