Journal Club Articles, 04/29/2015

N Engl J Med. 2015 Apr 25. [Epub ahead of print]
Therapeutic Hypothermia after Out-of-Hospital Cardiac Arrest in Children.
http://www.nejm.org/doi/pdf/10.1056/NEJMoa1411480

N Engl J Med. 2015 Apr 2;372(14):1312-23. doi: 10.1056/NEJMoa1406330.
Antibiotic treatment strategies for community-acquired pneumonia in adults.
http://www.nejm.org/doi/pdf/10.1056/NEJMoa1406330

Wednesday Lectures, 04/29/2015

TTHM 11.4 PDR/TLLT  (4/29) An Update on Blunt Abdominal Trauma

10a ~ Paolo

Case Study, Ibeam to the chest

Second FAST exam increases sensitivity in blunt abdominal trauma…

Trauma CTs, PanScan utility? Appears to have Mortality benefit, but may have bias relating to selecction & diagnosis lead time…

Repeat CT without Contrast? Pretty good for hollow viscous injury…

FAST ~ find nothing then nothing changes, PanCT not going away, hollow viscous doesn’t need contast…

ATLS circulation & hemorrhage control…

Early aggressive crystalloid resuscitation, not great for blunt trauma.  More IVF, the worse they did… 1L challenge ok, then dose~effect response with worse outcomes somewhere <5L total.  In elderly people, >1L can increase mortality!  Resuscitate too the BP… 3 studies in humans on permissive hypotension… 1994 significant, but trials 2&3 say no difference… Left with anecdotal evidence otherwise… EMS giving RBC vs crystalloid, did much much better.

Permissive HoTN NEVER in context of TBI!!!  “Salt water continues to not carry oxygen.”

Hemodynamic Resuscitation 1:1:1? If you live long enough to get 1:1:1, mortality is skewed by selection bias of survival…

PROPER Study in JAMA prospective on 1:1:2 (RBC) only difference was death dt hemorrhage… less in the 1:1:1?! but no overall mortality benefit between groups.

TXA! CRASH2 trial lysine analog to inhibit fibrinolysis… Early administration by EMS may be efficacious, but not as useful dt by the time of Massive Transfusion Protocols… effective but can cause clots.  “Any drug that causes you not to bleed will cause you to clot”.

Early initial studies always show maximum benefit, minimal harm…

 

11a ~ PSQ (Kajla, Shaw)

Read your own films… Signout Radio calls ?EPIC funtionality… Beware complex presentations in elderly ppl with atypical symptoms…

 

1230p ~ TLLT (Schenker)

*Ibuprofen v Ketorolac? Efficacy similar… Gout Indomethacin NOT better than other NSAIDS.

Placebo of IV/IM versus po meds? Anecdotally, maybe, but poor evidence.  ALL NSAIDs cause bleeding.  We want to block COX2, but spare COX1 if possible…

*EM Dental: Front incisor fractures most common… #s 1 to 32 or Orthodontic R upper 1 to 8…

Ellis fractures: 1) Enamel, 2) Dentin, 3) Pulp, deeper need more intensive therapy.

Tooth Concussion ~ mechanism can cause tooth to be mobile in socket

Subluxation (loose) vs Luxation (displacement)… tooth can be jammed into alveolar bone…

Wisdom teeth can cause Pericoronitis or Operculum… can become infected, Penicillin or Clinda recommended…  “Vincent’s Disease” (ANUG) not to be confused with Herpetic Gingivostomatitis…

Alveolar Osteitis, aka “Dry Socket” should have Abx until dental follow up.

Ludwig’s Angina & Cavernous Sinus Thrombosis can be severe dental complications…

Post Extraction Bleeding, apply pressure, silver nitrate, surgicell or gel matrix foam…

Tongue Lacs may need deep & superficial sutures…

Lip lacs beware Vermillion border…

Dental Anesthesia, blocks… Oral Candidiasis (thrush)

Gingival Hyperplasia c phenytoin or CCBs…

Leukoplakia, progressing to squamous neoplasm on tongue…

“Magic mouthwash” ~ Viscous Lidocaine, Benadryl, Maalox (swish & spit)

 

130p ~ Journal Club (Haswell)

*Some benefit from Thoracotomy in select group of blunt trauma ED pts…

Having prior vitals or less CPR time helpful for outcomes.  Long down times are prognostically poor… uncertain for Thoracotomy vs base survivability… Only 1/2 of the surviving thoracotomies had possible beneficial interventions related to thoracotomy.

*Presyncope pts: who had poor outcomes?

Surprisingly high discharge rates in Canada? Followup access better?

Physicians do a good job at calling some things like PE, DVT, but poor at determining poor sequelae of syncope & presyncope.

 

230 ~ Faculty Grand Rounds (Sarsfield)

Stan Goettel (~Jay Scott) ~ ACLS & PALS… Instructor classes during TLLT/Admin…

Review of EM Clerkship… Observing H&Ps, clerkship goals & objectives, LCME objectives…

Developing plans, giving feedback, list of common complaints…

New Eval Cards & Give Feedback “This is Feedback”…

Signout Protocol? Need to be standardized?

*ALWAYS assign receiving resident/Attending BEFORE talking about the pt.

Typically we have one resident run signout & assign new residents, another resident comments.

When pts are discussed prior to assignments or designation as a “SIGNOUT” patient, this can cause miscommunication & confusion.

Wed Lectures, 4/22/2015: Contemporary Issues Conference

TTHM 11.3 (4/22/15) Contemporary Issues Conf

Infectious Diseases in EM

8a ~ Global Health & Malaria (Polhemus)

97 Countries c major transmission, 584K deaths per year, Anopheles mosquito…

Sporozoites, Liver parasite phase, merozoites, blood phase… (protozoan dsx)

  1. falciparum is “the malaria that kills”, parasitemia 1.3% low at <2%…

Artesunate & Malarone (Atovaquone/Proguanil) Rx… P.vivax (was “the weak malaria”)… changed to chloroquine Rx…

  1. knowlesii case report not caught by typical malarial quad screen antigen PCR, an “emerging 5th infection”  First discovered 1931 & was actually used for a time to induce fevers to trreat syphilis!?! Knowlesii found primarily in Malaysia, but also other southeast Asia.  Higher mortality, like falciparum.  Thrombocytopenia somewhat common, but knowlesii has no reports yet of severe anemia or cerebral malaria from this species.

“Binax Now” is the U.S. bedside test for falciparum, but still needs microscopy confirmation!

3 negative smears needed for full exclusion.  CDC guidelines helpful…

Coartem is new antimalarial as of 2009, but call ID if you suspect case, already increasing    resistance?!  Hyperparasitemia can be considered >2% blood parasite cell load.

Lactic Acidosis likely & major risk factor for severe disease & death.

JEM 2011 ~ Nigerian woman in US, sore throat, dry cough, mild fevers, similar presentation to Influenza.  Consider blood smear early in endemic travelers with septic symptoms!!!

 

830 ~ Arboviruses (Endy, Upstate ID Chief)

ARthropod BOrne Viruses… Aedes agypti & Ixodes…

Many of these viruses have vertical transmission (i.e. mosquito reproduction).  Virus induces behaviors in mosquitos to have smaller volume, increased frequency blood meals!

Systemic Fever:  Chikungunya, Onyongnyong, Ross River, Dengue…

Encephalitis Viruses (West Nile, EEE…) & Hemorrhagic fevers (Yellow Fever, Dengue)

(*Ebola is not an ARBOvirus)

Cicero Swamp ~ EEE… seasonal periodic outbreaks, Culiseta mosquitos primarily bird mosquitos.  Most encephalitis viruses come from bird preferring mosquitos.  Humans & horses become incidental hosts.  Bird migrations influence these ARBOvirus distributions.

*EEE is a togavirus (alphavirus), clinical manifestations vary… mortality once encephalitis develops ~50%!!! seasonal September, November greatest.

*JEV is highly endemic to Southeast Asia, Culex mosquitos, pigs are important vectors, can have high % viremia.  Humans & horses are incidental/dead~end hosts. Seasonal & also bird migratory influence, often Feb~March. Annual incidence up to 20/100K in affected areas. IAXARO vaccine can prevent JEV?!

*St.Louis (SLEV) used to be most common in North America… (?)

*Powassan Encephalitis is Tick Transmitted flavivirus, c seasonal tick cycle, increasing incidence over last several years, still pretty rare (12/yr U.S.).

*Key West, Fla… Dengue Hemorrhagic Fever (research in Thailand), Aedes agypti (common urban mosquito), 4 serotypes, most hemorrhagic is Serotype #2.  Flavivirus, variety of clinical appearances.  Petechiae common in serious cases, thrombocytopenia & rapid shock can occur!

Fluid resuscitation important, & beware GI bleeding.

*CDC “ARBOnet” <diseasemaps.usgs.gov>

 

9a ~ Influenza (Javaid)

Every year it’s a big deal.  Hemagglutinin Antigenic Shift causes major problems to ongoing immunity.  Frequent Epidemics (i.e. 1918 Spanish Flu, may share partial immunity to previous strains) & Infrequent Pandemics (more complete antigenic shift of new strains)…

Spanish Flu caused 20 to 100 Million Deaths!

Annual Flu 3 to 46K Deaths… BEST utility of vaccines?

“HAN” Health Alert Network… Antigenic Shift > Drift…

2014~15 similar to the prior couple seasons, mild season 3 years ago.  Worst in the elderly.

Predicting Bird Flu, Swine Flu, other Flu strains is difficult anticipatory model…

Oseltamivir still fairly effective, Amantidine no longer effective, but limited options if resistance develops.

 

930 ~ Pandemics (Joslin)

Pandemic is a Global Epidemic of infectious Disease, across very large area…

Epidemic is greater than anticipated occurrence of infectious diseases, (?regional, intermediate)

Outbreak is initial local occurrence of greater than anticipated ID incidence.

1918 Spanish Flu, 20M deaths

1957 Asian Flu, 1M deaths

1968 Hong Kong Flu, 1M deaths

2009 H1N1, 14K deaths

SARS, MERS, Ebola… not so much…

Epidemics: Polio, Cholera, Yellow Fever, Dengue…

Outbreaks: EV.D68 last year, Ebola…

When should pts & parents stay home? from school/work? from the hospital?

DOH & CDC public messaging…

Consider when treatment is necessary or not? Tamiflu controversy?!

Admission criteria? Who needs what resources, for pt outcomes? & epidemiology outcomes?

Alternative Care Sites (i.e. Fairgrounds Infirmary as backup site?!)

Who takes care of the Ebola pts? Residents v Attendings… Protocols? PPE?

Training, Education, & Time/Resource Committment…

 

1020 ~ Hepatitis (Brodey)

Formerly treated by GI > ID…

*HepC has NY mandated testing offering, ED & Obs exempt…  Testing drugs available, but potentially expensive.  …though cirrhosis & complications also expensive.  Prevalence in Population in ED (U Alabama) ~8% confirmed Positive HepC!

POCT? Who gets the results? What to do with results? Clinic followup? Treatment?

Needlestick exposure… initial POS screening Ab test needs quantitative verification c viral load.

Many false POS. Overall chance of NOT getting HepC ~99% from needlestick. …BUT 20% self limited c complete resolution.  NO postexposure Ppx.

*HepB treatable, should have vaccines & exposure IG/consider booster?

 

1050 ~ HIV (Reddy, Director of AIDs Center here)

35 Million infected worldwide, 3.2 Million children, mostly in SubSaharan Africa.

1.2 Million have HIV in the U.S.  Florida has highest Incidence Rate now.  High rates in MSM & African Americans… Sexual Transmission now > IVDU as transmission vector.

132K c HIV in NYS, but only 1 in 5 is Upstate NY?! Early DxTx improves outcomes.

ELISA testing very specific confirmatory test, doesn’t automatically need viral load.  New Alere HIV 1&2 Ag/Ab test becoming more available… NYS required to offer ED testing, CDC offers extensive guidelines.

Neurologic Complaints diverge by CD4 count (Low <100? <350?)

Opportunistic: Toxo, PML, CNS lymphoma, Fungal…

Cardiovascular Conditions very common in HIV with any CD4 level.

Truvada preexposure HIV Ppx pill for HIV NEG high risk pts! can be obtained from HIV clinic.

 

1120 ~ Occupational Hazards (Dwyer, BioEthics)

Treating the unknown ~ HIV discovery hazards…

Quarantine? ~ SARS…

Medical Missionaries ~ Ebola & Lassa Fevers…

Exposures common.  Bad anecdotes but statistical risk?  Compared to other occupations…

100 doctors/year die in Auto Accidents!  ~100 doctor suicides/year! …Compared to 3 deaths per year related to exposure related illness.  Physician work related mortality about average to population, although Psych & ED slightly higher.

Duty to Care? Yes, but limited to “reasonable risk”

Fair procedures & policies for quarantine & segregation of infectious patients: fair & adequate resource allocation?  Who gets designated an Ebola Center? Upstate designated by governor as 1 of 8 in the state.

Childcare for healthcare providers in Emergencies? Survivors benefits for firefighters in NYS are good; what about healthcare workers?

 

1150 ~ Ebola Response (Dufort, from Albany Med Pediatrics & ID, Epidemiology NYS DOH)

Can you opt out of CPR on Ebola patients?  How’s it going in Africa?  Approach to Ebola in the ED (State & National plans)?

Travel Monitoring Program ~ “CARE” kits (check & report ebola) at JFK, Newark, Washington~Dulles, Atlanta, & Chicago~OHare International airports.

“PUI” ~ person under investigation… what if they have a non~infectious need for medical care?  Allocate resources from a designated center? under which conditions?

 

130 ~ Mandated ED ID Testing (Panel…)

Who can opt out to avoid exposures? ED Attendings, probably not in most cases… Some residents wanted to be part of the don & doff training… Senior residents? Financial limitations for training at Upstate influencing policy… Back to the idea of “unfunded mandate”?

Airborne v Droplet v Contact v Blood Exposure Precautions… which cause ethical & logistical problems? ~ Really context dependent!

Public Policy… How much in the way of public resources should be devoted to healthcare workers in terms of risk compensation with insurance & disability coverage on a larger or more specific level?

Did Ebola & other “crises” desensitize the public to appropriate disease response? Is there too much conterreaction to the “wave of preparedness”?  Is the CDC message about initial exposure hospitals realistic? or did they undercut physician trust in the organization?

Do we need to clean waiting rooms better?  ED challenges: how do we react to delayed implementation of infectious precautions?

 

230 ~ Sepsis (“McCabe lecture”, Paolo)

Case of kid with simple elbow cut, 5 days later died from TSS!  So what is our threshold?  Are our tools both sensitive and specific enough not to miss this?  Legislators make regulations to try & make bad things stop happening to good people…  Clinical Intuition/Gestalt actually pattern recognition ~ how useful for telling sick or not sick?  Challenging not to do too much or too little, in the moderately sick patients…

SIRS to Sepsis… VERY nonspecific… …AND not even that sensitive! Misses 1/8!

Sensitivity 69%, Specificity 35%?!?!  DOES NOT WORK?!?!

SIRS has infection in only 26%!  “Other” is 56%, with greatest subcategory “mental health disorder”?!  15% of ALL ED Peds patients come in with SIRS!  Of THESE, 81% were discharged, with NO IV, & NO readmission!  (Only ~5% total ADM for ALL Peds!)

Is Bandemia predictive? Evidence is poor.  Does not distinguish bacterial from viral reliably!  Lactate lacks Specificity, possibly correlates with severity… There must be a balance between miss rate & overdiagnosis rate.  There are poor anecdotes on both ends of the spectrum, with some overlap.  Not always a perfect answer.  We want to harm the least & Diagnose the most accurately…

EGDT & Surviving Sepsis campaigns… effective? At first, perhaps, but now ProMISe, ARISE & ProCESS trials show lack of efficacy of EGDT compared to “standard care”.  IVF & ABX are effective.  CVPs found unhelpful for predicting IVF responsiveness.  US as surrogate for CVP no more helpful, though less invasive… Leg Raise possibly helpful to assess IVF responsiveness.

*Lactate ~ bad when elevated c hypotension.  However, in normotensive individuals, not always helpful, especially since different cutoffs used… 4? Remeasurement of lactate not necessarily useful, but is pretty standard at present.  Pressors in shock found mortality difference with delays of ~14 hours.  Dopamine possibly more arrhythmogenic, but no total mortality benefit in Cochrane Review.  Linear relation for time to Abx & Mortality, even >IVF.

“We take care of awful anecdotes all the time.” Ppl are living longer, immunomodulators, treat as appropriate, not too much, not too little, so much as possible.

Rothman adds: Slides and handouts linked below:

handout_Javaid_influenza

handout_Paolo_Sepsis_slides

handout_Polhemus_Malaria

hanout_panel_discussion_questions

handout_dwyer

handout_endy_slides

Wednesday Lectures, 4/8/2015: Seizures Day

TTHM 11.1 Seizures Day (Tint. Ch. 129, 165, 168, 191)

Fun fact: Pseudoseizures by ICD9 ~ “Dissociative Convulsions”

 

8a ~ Trauma Conference ~ PM&R (Hurlong)

…basically, Upstate should establish closer relationships with SNFs for social & placement considerations, continue work with multidisciplinary team…

 

10a ~ Seizure Disorders (Prasad)

Most are convulsive, but may also be absence.

Simple Partial (maintains consciousness)

Complex Partial/Generalized (consciousness lost or impaired)

Be careful of label “noncompliant”, associated c stigma when medication difficulties may be dt lack of understanding by pt… ACDs also associated c significant side effects leading to lack of tolerability by pt.

Ketogenic Diet may be helpful in childhood epilepsy?

Prolactin level within ~20 min may help distinguish from nonepileptic Sz, & EEG may distinguish acutely.

 

1030a ~ Status Epilepticus (Paolo)

*Diagnose: Convulsing or not… “5 MIN” is “STATUS”!

Treat, Benzo, AEDs, B6, intubate & propofol.

Status can be nonconvulsive AMS.  25% of Coma pts found on EEG to be nonconvulsive status.

Critical underlying illness in ~14% of nonconvulsive status.

Which benzo best for Seizures? Lorazepam slightly better than Diazepam per Cochrane 2014.

Although prehospital IM Versed seems to work slightly better than Ativan? Quicker?

Meta Analysis of 2nd line agents… Keppra > Phenytoin, but Valproate even better?! Phenobarb also very good but much more respiratory suppression.

Propofol can cause “PIS” ~ propofol infusion syndrome, usually after complex prolonged polypharmacy… & sedation associated c worse general outcomes, independent of underlying illness?!

 

11a ~ Small Groups (Barus, KNacca) LP & CSF studies…

SIM INH B6, & Peds Sz Jeopardy

 

12p ~ Rapid Procedure Lab (Vatti) Fiberoptic intubations

 

1230p ~ Jr/Sr Sessions (Lavoie, Paolo)

Lumbar Puncture needs INR<1.4 or Plts <50K (?80K) & consideration of other anticoagulation risks. Aim L3~L4~L5, a little lower in peds potentially (stay below L3)

 

130p ~ CNS Infections (Lavoie)

Meningitis ~ bimodal distribution… mostly children under 5, also old ppl.

Only ~4% is bacterial, mostly viral causes.

(Strep pneumococcus, H.flu, N. meningococcus, …also consider listeria in young & old)

If you suspect bacterial meningitis, give antibiotics. Early is better.

Steroids plus or minus, poor evidence for benefit, unlikely harm unless Vanco levels affected.

Ceftriaxone probably first, Acyclovir…

Droplet precautions until Neisseria excluded.  Close contact prophylaxis c 1 dose Cipro vs 4 dose Rifampin.

 

2p ~ Tox Seizures (Marraffa) ~ multifactorial, caused by:

*Adenosine down (antagonism) ~caffeine, theophylline

*GABA down (inhibition or depletion)

*Na down (blockers) ~buproprion, carbemaz, citalopram, “caine” drugs, TCAs, propranolol

*EAA up (Excitatory Amino Acids) ~cocaine, EtOH/benzo withdrawl, amphetamines

*ACh up (cholinomimetic & acetylcholinesterase inhibition)

~23% Buproprion! in Sz by drug type.  Other, Antidepressants, Diphen, Tramadol, TCAs, Amphetamines, Venlafaxine…

Serotonin agonism may ~ SIADH, hyponatremia

INH needs B6! Think about B6 after 2nd line attempt!!! Similar c gyromitra & methylhydrazine

B6:INH 1:1 or 5 grams (50 vials) or 70mg/kg in peds…

higher doses of B6 can have toxicity though?! & synergistic effect c additional benzos

 

230p ~ Febrile Sz (Hanley)

Simple Febrile Seizure needs:

*Fever

*<15min (Neuro Lit says 30min)

*Age 6mo~5yrs

*generalized

*no recurrence within 24 hrs, nor persisting/focal neuro abnormality

For concerns about bacterial source of fever, CXR & UA likely more useful than other labs.

Remember though, ~1/3 of febrile Sz are complex & have limited evidence or guidelines.

…?LP?… consider status after recovery.  Good return to baseline may indicate low risk & LP can be avoided in some cases based on Hx & Sx factors.

After checking glucose: 2 doses benzos, 5 min ea, then consider phenobarb, or fosphenytoin 20 mg/kg (>phenytoin dt vascular irritation, hypotension, arrhythmia risk), keppra?/depakote?/B6/intubation.

 

3p ~ Neonatal Sz (Thabet)

Most neonatal Sz are NOT neonatal epilepsy (syndromes).

Focal, clonic? Did it stop with restraint?

Hiccups or apparent tics, pedaling or cycling of legs can be concerning.  True seizures do not resolve c restraint.

Neonatal period most common frequency of seizure onset per unit time, & phenobarb common 1st line, don’t forget B6, & high mortality, up to 20%!?!

From Dr. Johnson – Two NEJM Articles

“I find myself talking of the need to treat sterile pyuria a lot in the ED…”
Sterile Pyuria
http://www.nejm.org/doi/full/10.1056/NEJMra1410052
Gilbert J. Wise, M.D., and Peter N. Schlegel, M.D.
N Engl J Med 2015; 372:1048-1054March 12, 2015DOI: 10.1056/NEJMra1410052

 

 

“…an editorial re a paper on antibiotic care of skin infections…It doesn’t answer all the questions we want answered, but I think the last 3 paragraphs are a reasonable approach…”
Choosing an Antibiotic for Skin Infections
http://www.nejm.org/doi/full/10.1056/NEJMe1500331
Michael R. Wessels, M.D.
N Engl J Med 2015; 372:1164-1165March 19, 2015DOI: 10.1056/NEJMe1500331

Last three paragraphs:

EVALUATION OF PATIENTS WITH STERILE PYURIA
As noted above, the differential diagnosis of sterile pyuria is broad (FIGURE 1). A complete history and physical examination with consideration of the factors listed in Table 1 are required to identify the potential causes of genitourinary inflammation. Specific evaluation for sexually transmitted infections is warranted. Evaluation to detect bacterial, fungal, and parasitic infections is indicated in patients with a clinical history that suggests specific infections.

Abdominal, renal, and bladder imaging should be considered for evaluation of febrile or otherwise symptomatic patients. Inflammatory conditions near the urinary tract as well as systemic diseases should be included in the differential diagnosis (TABLE 2). Sterile pyuria has historically been considered to be suggestive of genitourinary tuberculosis, but a wide variety of other causes must be considered.

Criteria for successful treatment of conditions that cause sterile pyuria include curtailment or resolution of symptoms, a negative culture, or a negative PCR assay. Pyuria may persist because of underlying inflammatory changes.