EMU Monthly – July 2015

July 2015

  • It’s July and that is Fireworks time in the USA image001 – or these fireworks -> image002so let’s start off with a boom. Sepsis is a bothersome entity and generally the most common pathway to demise- a sorrowful state that is not worthwhile to go toimage004 This is an excellent review of sepsis and septic shock, but since I am a Scott Weingart groupie image006and a lover of septic shock – I have kept you up to date with lots of this and even if you still are hungry- Scott has a great site on ICU medicine called EM CRIT. ICU network is also a great site. Here are two reminders-everyone knows that sepsis gets real bad with a lactate greater than 4 but outcomes are actually worse in the 2- 4 range and even high normal lactates. image008 Also another point I should make is that DIC – according to guidelines- doesn’t take that much to make the diagnosis – you just need an INR greater than 1.5 and platelets less than 100000 and a clinical picture. (Emerg Clinic Nor AM 32(4)759) TBTR: Septic shock – lactate facts and watch out for DIC. Now let’s get a little deeper into ICU med- as you all know I am a big fan of ICU giant Paul Marik and he takes on the goal directed sepsis campaign from a different angle. Manny Rivers asks for a CVP greater than 8 but Marik points out that simply this increases interstitial fluid and compromises renal and cardiac blood flow.image010 Balanced salt solutions cause fewer problems as fluid therapy, but also not at CVP of more than 8image012 (Ann ICU 4:21) TBTR: Should we be flooding patients?  Want more of ICU jazz and probable comments on how little we EPs know from the ICU guys? See this month’s essay.image013
  • Your stethoscope is filthy image014because you do not clean it between patients. So are your shirtsleeves. And your pen. And pig pen as well Now your wheel chairs are filthy too ( AM J Inf Control 42(11)1173) Honestly we have patients with all kinds of excretions secretions and pee- cretions on these chairs and who cleans them? TBTR: wheel chairs need to be cleaned well. So do a lot of our patients. TBTR: clean those wheel chairs – and while you are at it- those ultrasound probes alsoimage016
  • There have been many articles on this subject and this is just another one trying to piece together how circadian rhythm is related to cancer but there is no doubt- working nights can cause breast cancer. (End Rel Canc 21(4)629). It is time for quotes and I bet you think you know what the quotes are going to be this month- right! air traffic controller and airline funny quotes: From an unknown aircraft waiting in a very long takeoff queue: “I’m f***** bored!” Ground Traffic Control: “Last aircraft transmitting, identify yourself immediately!” Unknown aircraft: “I said I was f*** bored, not f****stupid!”
  • I’m getting old and opinionated and becoming a disagreeable old crock-(actually I am only 55) but I hate the paternalistic “physicians are making terrible mistakes”- we need the (name the specialists of your choice) to save us from medical apocalypse. This time it is the pimple pinchers – the dermatologists feel we are calling everything cellulitis and as such over prescribing antibiotics. So that’s fine, my dear Derm colleagues, but at least do some research to prove it. They bring 29 cases where PCPs misdiagnosed cellulitis- not exactly proof of anything. However the list of missed diagnosis may be of interest. 2 cases actually were cellulitis. 2 were arthropod reaction- I think all of us could and should be able to tell the difference. By the way – cellulitis from mosquito bites and bee stings are not that common. Gout and stasis dermatitis are diagnoses that in some cases can be confused with cellulitis but there should be other clues to help you here. Molluscum contagiosum – let’s be real. Hematoma is also another diagnosis I am not sure how you would miss. Chronic paronychia another case you should know what to see. Eczematous dermatitis and erythema nodosum – these should also not be so hard, Erythema migrans- OK, I could miss that but it doesn’t look so much like rip roaring cellulitis. (JAMA Derm 150(10)1061). I was a little surprised they didn’t mention Sweet’s syndrome – a case we have discussed in our clinical challenges in the past. TBTR: All that’s red is not cellulitis. All that wheezes is not asthma. All that is horseradish is not a horse chestnut. A DC-10 had come in a little long and thus had an exceedingly long roll out after touching down. San Jose Tower noted: “American 751, make a hard right turn at the end of the runway, if you are able. If you are not able, take the Guadalupe exit off Highway 101, make a right at the lights and return to the airport.”
  • Its ortho time so if you don’t like ortho you may want to skip the next few paragraphs- or even better – go read something more enlightening like the Annals of Activated Sludge journal. So kids get fractures- we know that you can be pretty liberal in leaving some displacement most of the time – but even in those you do do manipulation – they can heal still angulated.  So they examined who needed to be re manipulated.(Arch Ortho Trauma Surg 134(12)1699)   Now I know you are not going to do re manipulations in the ED or office even if you are manipulative. But I saw something else in this article – maybe they didn’t need to be manipulated in the first place. This study is on the forearm- the area most likely for fractures in kids and they say the following based on how they see remodeling- less than nine years old you can have 30 degrees of angulation, 25 degree in 9-12 years olds and 20 degree for greater than 20 year olds. TBTR: re manipulations of most pediatric fractures are usually unnecessary. Then again – manipulations in the first place may be unnecessary. A Pan Am 727 flight waiting for start clearance in Munich overheard the following -Lufthansa (in German): “Ground, what is our start clearance time?” Ground (in English): “If you want an answer you must speak in English.” Lufthansa (in English): “I am a German, flying a German airplane, in Germany. Why must I speak English?” Unknown voice from another plane (in a beautiful British accent): “Because you lost the bloody war.” image018
  • The Danes were great in their research for this article and really did a good job in casing the literature to answer the important question – what factors influence non union and mal union of clavicle fractures.   For sure displacement plays a function, but they weren’t rally able to identify to what degree and what other factors play a role. Here is the key point- treating displaced fractures with surgery will give better outcomes (not sure how they knew that) but treating all displacements with surgery will lead to overtreatment of many fractures. (Int Ortho 38(12)2543) Pretty heady stuff for an orthopedic journal, especially one that no one reads. I don’t send many of these for surgery- do you? TBTR: Surgery for clavicle fractures? Good results but this is not for everyone. While showing the use of the oxygen mask: “If you are seated next to a child or someone acting like one, please assist them in putting on the breathing apparatus”. Pilot: “Folks, we have reached our cruising altitude now, so I am going to switch the seat belt sign off. Feel free to move about as you wish, but please stay inside the plane till we land. It’s a bit cold outside, and if you walk on the wings it affects the flight pattern.”
  • We don’t like to give NSAIDS in pregnancy, and triptans – well, they are still category C. In this study, giving meds p.o. for migrainers in pregnancy didn’t help at all. IV – a precious few. What did work were peripheral nerve blocks that are usually an occipital nerve block. (see EMU in the past using our search function – which would be a great idea if the website was functioning but it isn’t now – by the time you read this – it will be)  (Obs Gyn 124(6)1169) Sounds great the percentages are very convincing but they did 27 blocks in only 12 patients- why so many in the same patients? But I would consider it – they are really easy to perform. TBTR: Consider nerve blocking in migraine of pregnancy. From a Southwest Airlines employee: “Welcome aboard Southwest Flight XXX to YYY. To operate your seat belt, insert the metal tab into the buckle, and pull tight. It works just like every other seat belt and if you don’t know how to operate one, you probably shouldn’t be out in public unsupervised.  In the event of a sudden loss of cabin pressure, oxygen masks will descend from the ceiling. Stop screaming, grab the mask, and pull it over your face. If you have a small child traveling with you, secure your mask before assisting with theirs. If you are traveling with two small children, decide now which one you love more.”
  • I don’t know why I feel an obligation to abstract every article that Ian Stiell produces but then again OCD has gotten me out of bed a lot of times when I would have been better off staying there. Ian is looking at the optimal chest compression depth in CPR- an often studied issue. Of course the study was done with excellent methods- and not on dummies either. They found that the recommended 50 mm depth and no upper limit was too much – there is more survival with 40.3- to 55.3 mm. (Circ 130(22)1962) This makes sense to me- you don’t need to squish the heart.  But then again – how can we ask someone in the field to do this? How will they know if they are doing 55.3 or 55.4 mm? And let me say another thing- while I have no evidence to prove it- I do not like the hit hard hit fast campaign- I think you need to fill the heart- cardiac output is the name of the game here. TBTR: probably do not need to crush the chest so hard in CPR.

While taxiing at London’s Gatwick Airport, the crew of a US Air flight departing for Ft. Lauderdale made a wrong turn and came nose to nose with a United 727. An irate female ground controller lashed out at the US Air crew, screaming: “US Air 2771, where the hell are you going?! I told you to turn right onto Charlie taxiway! You turned right on Delta! Stop right there. I know it’s difficult for you to tell the difference between C and D, but get it right!” Continuing her rage to the embarrassed crew, she was now shouting hysterically: “God! Now you’ve screwed everything up! It’ll take forever to sort this out! You stay right there and don’t move till I tell you to! You can expect progressive taxi instructions in about half an hour and I want you to go exactly where I tell you, when I tell you, and how I tell you! You got that, US Air 2771?” US Air 2771: “Yes, ma’am,” the humbled crew responded. Naturally, the ground control communications frequency fell terribly silent after the verbal bashing of US Air 2771. Nobody wanted to chance engaging the irate ground controller in her current state of mind. Tension in every cockpit out around Gatwick was definitely running high. Just then an unknown pilot broke the silence and keyed his microphone, asking: “Wasn’t I married to you once?”

  • Meds can cause ataxia. Well then, so can being drunk and it is lot more fun. They reviewed the literature and found this to be quite common and even provide an extensive list of drugs that can do it (CNS Drugs 28(12)1139) But this is a good example of case report disease. If it is rare enough to be a case report – it isn’t something you need to be so worried about. If you sift through the article and review the meds that have equal or more than 10 patients who have had ataxia with these meds- you only find four medications- lithium, lamotrigine, metronidazole and pregabalin. Does that mean I would rather you fall on your face and not give me your trichomonas? Well, now that you mention it….. TBTR: A few drugs can cause ataxia as a side effect. Most of the time, it goes away after discontinuing the drug. Tower: “Eastern 702, cleared for takeoff, contact Departure on frequency 124.7” Eastern 702: “Tower, Eastern 702 switching to Departure. By the way, after we lifted off we saw some kind of dead animal on the far end of the runway.” Tower: “Continental 635, cleared for takeoff behind Eastern 702, contact Departure on frequency 124.7. Did you copy that report from Eastern 702?” Continental 635: “Continental 635, cleared for takeoff, Roger; and yes, we copied Eastern and we’ve already notified our caterers.”
  • SEIZURE!!! Now what? OK, well, just get the diazepam or the midazolam in – but wait- they have benzo resistant status epileptcus- now what? Well, for all you lovers of paraldehyde- it is out of the protocol although you may find some old timers still looking for it (or sniffing it).  But they look at five agents in particular: Pheyntoin and Fosphenytoin – not reliable enough. Phenobarb – works well, but this is an automatic intubation. Valproate- my personal favorite- they like it less since it can cause liver failure although I never saw this. Keppra (levetiracetam) is their number one choice with lacosamide being a possibility with no evidence but it looks promising.(Seizure 23(3)167) Recall that they just looked at these five common drugs- and the best choices  are very expensive and not even available to me in my ED. Propofol and ketamine are my first choices. TBTR: Keppra IV seems to be the best bet for benzo resistant seizures, but do not forget Propofol in my opinion.  After a particularly rough landing during thunderstorms in Memphis, a flight attendant on a Northwest flight announced: “Please take care when opening the overhead compartments because, after a landing like that, sure as hell everything has shifted.”

“As you exit the plane, please make sure to gather all of your belongings. Anything left behind will be distributed evenly among the flight attendants. Please do not leave children or spouses.”

  • This is a pretty sparse month – there just were not that many good articles. –so let’s get to a clinical quiz. It is an easy one – a large mass in the chest although it can be found anywhere in the body. No silly, it isn’t AIDS, lymphoma or ectopic hemorrhoids. This is simply: (J Caridothor Surg 9:170) An airline pilot wrote that on this particular flight he had hammered his ship into the runway really hard. The airline had a policy which required the first officer to stand at the door while the passengers exited, smile, and give them a, “Thanks for flying XYZ airline.” He said that in light of his bad landing, he had a hard time looking the passengers in the eye, thinking that someone would have a smart comment. Finally, everyone had gotten off except for this little old lady walking with a cane. She said, “Sonny, did we land or were we shot down
  • This is the sort of article that everyone should read and nobody will. It is on a subject about as popular as going shoe shopping with your wife or watching bobbing for pickles in Ypsilanti Michigan- Father (BTW, I want to laud Father on his calling Shared decision-making Docs as pinhead liberals- way to go, Tiger)- they must have a polka for that, no? But the title is “Clinical Trials – What a Waste”- and the author is someone I do not know but Jerry Hoffman speaks very highly of- John Ioannidis. His point – how can we really know what the truth is when so many trials are discontinued, not published, or just lost – and we are only speaking about the ones that were registered. Throw in spin that authors put on studies and the fact that harm is often overlooked in favor of benefit and it becomes an abyss (or an abscess). Then he goes for the jugular- many trials ask dumb or insignificant questions, and some are the paper chase- like in Israel and Turkey and Europe where you get a teaching position only based on how much you publish (BMJ 10:1136 g7089) image019 Fortunately he did consider EMU in this rant – it too is such a waste. TBTR: Clinical trials –what do they mean? Do they mean anything? After a real crusher of a landing in Phoenix, the flight attendant got on the PA and said, “Ladies and gentlemen, please remain in your seats until Captain Crash and the crew have brought the aircraft to a screeching halt up against the gate. And, once the tire smoke has cleared and the warning bells are silenced, we’ll open the door and you can pick your way through the wreckage to the terminal.”
  • What a mess of an article. But you can even learn from sifting through the trash. The title of this article was the efficacy of assisted self-reduction technique for anterior shoulder dislocation. But to be frank – the residents did all the reductions I couldn’t figure out what the “self-reduction” was. Furthermore they only did the reduction technique when there was one of the senior authors in the ED. They told them the reduction wouldn’t hurt (ethical?) and indeed 78 refused to enlist because of fear of pain. (Arch Ortho Traum Surg 134:1761) However, what we can learn is they used the Kocher technique – a technique shunned by most ED physicians because of fear of brachial plexuses injuries but in this study the results were excellent and even allowed them to make the supposition that this can be done by the patient by themselves. Forgot how to do this? image021Here it is:

Fig. 3. Reducing humeral dislocation by Kocher’s method

  1. crooking in the elbow joint with a putting of shoulder to the trunk.
  2. Traction downward and simultaneously rotation of a shoulder.

c-d stages – raising of arm upwards and simultaneously rotation of a shoulder with the following throw of hand on the healthy supershoulder. There is a youtube of this as well. TBTR: Kocher is back – may be even in your clinic! From the pilot during his welcome message: “We are pleased to have some of the best flight attendants in the industry. Unfortunately none of them are on this flight.”     Part of a flight attendant’s arrival announcement: “We’d like to thank you folks for flying with us today And, the next time you get the insane urge to go blasting through the skies in a pressurized metal tube, we hope you’ll think of us here at US Airways.”

  • I am an old fashioned guy and learned CVP lines by landmarks. In this article they did it by US direction – and still nailed the carotid (and even better they injected Propofol and gave the patient a CVA). What could possibly have gone wrong in this scenario? Probably the most common cause is that in 50% of people the IJ veins overly their carotids. However, they have a list of other possibilities and encourage us to check placement with backflow pulsatility, transduction of central pressure wave form, ABGs of blood and double check with ultrasound. Blood color may not be reliable. But perhaps the most important point is that if you do puncture an artery – if your needle is less than 7 French compress and image (rule out hematoma, pseudo aneurysm and fistula) if it is bigger than 7 French –leave it!!!!- let vascular deal with this problem. (Anaest Int Care 42:795 see also p696) TBTR: CVP lines – arterial punctures –what to do if you blew it and how to avoid it. United cargo jet (with female pilot): “This is my secondary radio. Is my transmission still fuzzy? Oakland ARTCC controller: “I don’t know. I’ve never seen it.”
    “Mumbai, what number am I in the landing sequence?” “By the time you land, sir, you will be number one.”
  • Short month this month – just wasn’t that many articles but that is OK, because you need to catch up on the old issues – the website was down for too long. As the plane landed and was coming to a stop at Washington National, a lone voice came over the loudspeaker: “Whoa, big fella. Whoa!”
  • Did you get number 11? It wasn’t too tough was it? You didn’t weasel out because it is from a chest surgery journal did you? This was Castleman’s Disease – a benign lymphoproliferative disease. The captain of a Vueling Airlines flight greeted passengers to Madrid this way: “We have a safety problem with the door at the front. Don’t worry, it’s just a safety problem.” After landing: “Thank you for flying Delta Business Express. We hope you enjoyed giving us the business as much as we enjoyed taking you for a ride.”

EMU LOOKS AT I SEE YOU

If you are an FP I’ll say so long now for this month – there wasn’t a lot of primary care this month – but don’t forget to tune in next month. For you ICU lovers – let’s go over the basic with inotropes and pressors. The source for this article is Emerg Clinic of NA 32:823

  • Look, ICU is fun and these guys are about into physiology as you can be – however, I want to keep this as practical as possible so we will omit that stuff – just get the article if you want more on the physio
  • These are the drugs you will probably be seeing in your tool box. Norepiniepheine (Norep) Vasopressin, dopamine, epinephrine (epi, adrenalin) isoproterenol, dobutamine, milrinone and levosimenadan The last three are inotropes.
  • Norep is the star these days. In a lot of countries its trade name is Levophed. It has strong alpha 1 activity with modest beta 1- meaning strong increases in blood pressure and minimal effect on cardiac output. Chrontropic effects- that is heart rate elevation is also minimal. This is still the go to drug for septic and cardiogenic shock (of course until you go to cath). This also seems to be the drug of choice for post resus care and neurogenic shock although here you may use dopamine since in neurogenic shock there is often bradycardia.
  • Vasopressin is making a move to the forefront as well. This med has very little effect on cardiac output. However, it works synergistically with nor epi and therefore can reduce the dosage that is needed. Just remember with vasopressin – there is no titration. May be a good drug in cardiogenic shock.
  • I will speak about Dopamine but this should not be drug you are using too often. True that dopamine at low doses causes vasodilation and diuresis but this is mild and probably of no clinical significance. Let me make this clear – low dose dopamine does not increase GFR, is no protection against oliguria, increases in creatinine or progression to dialysis. The small increase in splanchnic blood flow does not affect any measure of mesenteric blood flow. Intermediate doses increase the endogenous nor ep release and that causes increases in SVR. High dosages cause a lot of vasoconstriction. This drug causes a lot of arrhythmias, and seems that it may increase mortality. They say you can use this when there is a low risk of tachy arrhythmias but I only use it when there is profound bradycardia. Furthermore the idea that dopamine cannot cause damage if it extravasates so it can be given in a peripheral IV has been challenged. Also I have seen some literature that says you need catecholamine since dopamine increases nor ep release, so in a catecholamine depleted patient it may not work. This may also be a reason to avoid this drug.
  • Yo, Epi – this drug does it all –vasoconstriction, inotropy and bronchodilation. And an added benefit – at high doses, it causes coronary vasodilation. But the down side – this has the highest rate of arrhythmias and splanchnic vasoconstriction. Of course you do know that this is the drug for anaphylaxis- badness rarely occurs after IM administration. IV badness can occur but frequently this is because people use the 1:1000 dilution and not the 1:10000 one.IV badness is rarely seen in kids. You may need to add glucagon 1- 5 mg IV (0.03 mg/kg in kids until 1 mg max in kids) if the patient is on beta blockade and not responding to epi.
  • Here is the either you love it or hate it drug. Phenylnephrine. This works fast to get the SVR up – and goes off fast. That can help with temporary low blood pressures like from overaggressive NTG or Propofol IV. Also when you are waiting to put in a CVP for Nor Ep- this can be a good bridging drug. (although you can give Nor EP IV if you are 100% sure you the IV is in the right place) However it does cause a reflex brady cardia- this makes a lot of ICU guys to detest this drug. They say that it is only for patients with tachycardia and preserved stroke volume and that it significantly decreases stroke volume and splanchnic perfusion. However, recent studies have shown this to be a safe or at least safer drug than previously thought (see Crit Care 12:r143) but that study only had 32 patients. Personally I have no problem with it, and I like the fact that if it extavasates it causes no damage, and it is a good drug for the journey from the ED to the ICU.
  • Isopreternol- I do not know why I am even mentioning it. Yes it will get the heart rate up. And yes it is a strong inotrope. But it won’t change cardiac output and can cause cardiac ischemia. Maybe I will get nailed by my ICU guys, but I don’t know anyone who uses this.
  • Dobutamine—Really, I have nothing against this babe, she is beautiful and she makes you look macho when you use her- but I haven’t been involved with her for years. She is an inotrope and a mild chronotrope. She has some significant down sides. image022She can cause ischemia due to increased cardiac oxygen consumption, and can cause arrhythmias at any dose (all this is similar to isoproterenol but my cards guys say it is more common with the latter.) Dobutamine can lower the SVR a little; she also can cause tolerance within 72 hours, and looks terrible in an evening gown. There  could be a role for this in septic shock, but only if myocardial dysfunction is present which can only be inferred by ICU monitoring, or by signs of hypo perfusion despite maximal fluid and vasopressor therapy. The use of this drug in cardiogenic shock is – according to ACLS – when sBP is between 70-100. Watch for signs of ischemia or arrhythmia or keep checking the potassium
  • Milirinone sounds like Amrinone, which sounds like Amiodarone. Don’t mix them up. Millrinone is basically the second generation amironone which isn’t used any more. Amiodarone has no relation but I wish it wouldn’t be used anymore either. Millrinone increases cardiac output and reduces SVR. There is some pulmonary resistance reduction, so this theoretically may be better in pulm HTN.  It has a longer half-life than other inotropes and has no tolerance. Furthermore it can be given in a peripheral IV. Seems like a better choice than dobutamine. These drugs have traditionally been used in APE with lower blood pressures, but they say only to use these when cardiac index is impaired or left heart filling pressures are elevated – you got to know how to measure these.
  • Levosimendan is the new kid – increases cardiac output and increases GFR in APE. It may be cardio protective during ischemic events.  But alas, this is all unproven, and this medication is not available in my shop. And indeed, so far in studies; there is no mortality benefit over dobutamine.
  • And a very good way of increasing blood pressure is a drug called “fluids” these should be given concomitantly in most cases. What flavor fluids should you use? We spoke about that in the past.
  • Anyone notice I didn’t put in dosages? Well this is a good way to summarize :
Norepinephrine α 1 1 0.01–0.5 μg/kg/min Tachyarrhythmias, increased myocardial oxygen consumption, myocardial banding necrosis with prolonged infusions
Vasopressin α 1 , V 1 , V 2 , V 3 0.04 U/min Possible gastrointestinal hypoperfusion
Dopamine α 1 , β 1 , dopa 1 0.5–25 μg/kg/min Tachyarrhythmias, increased myocardial oxygen consumption
Epinephrine α 1 , β 1 , β 2 0.01–0.75 μg/kg/min Tachyarrhythmias, leukocytosis, increased myocardial oxygen consumption
Phenylephrine α 1 0.15–0.75 μg/kg/min Reflex bradycardia
Isoproterenol β 1 2 0.01–0.02 μg/kg/min Tachyarrhythmias, flushing, increased myocardial oxygen consumption
Dobutamine β 1 2 2.0–20 μg/kg/min Tachyarrhythmias, increased myocardial oxygen consumption, pharmacologic tolerance in prolonged infusions
Milrinone Phosphodiesterase inhibition 0.3–0.8 μg/kg/min Headache, hypotension, tachycardia
Levosimendan Increased calcium-dependent binding of troponin C 0.05–0.2 μg/kg/min Headache, hypotension, prolonged half-life of active metabolites

Yes I copied it from the article but you can get this information from many sources on the internet.

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