EMERGENCY MEDICINE UPDATE

SEPT 2013 1) Adenxal torsion- well, here is a score to help you- abdominal pain, o arian pain, !unbearable! pain!, omitin" and absence o# menorra"hia were all assi"ned points and these help ma$e a dia"nosis%&'um (eprod 2)&*+23,-+% . thin$ this is silly% They only saw 31 patients with this out o# /31 patients with pel ic pain and to tell you the truth- li$e testicular torsion- there does not seem to be subtle cases- i# they ha e they will loo$

sic$% . mean li$e- 01oh TA2E '34E 4ESSA5E6 Adnexal torsion patients loo$ sic$% This is not a dia"nosis you should miss% 2) (are that . brin" a 7E84 article but this one is so E4 &and written by an EP+ and yet had important points% 9eh, you $now the opiod syndrome- respiratory depression, miosis &absent in cocaine, and pethadine &which in the states is
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meperidine+ and in poly in"estion, stupor, hepatic in:ury, myo"lobinuria, rhabdo ,and hypothermia% ;ut there were some points that would be a shame to #or"et% 0o not #or"et <entanyl patches that can be on the body that can be in places that you may miss, and also $ids can chew on these and "et the opiod toxidrome% (emember paracetomol &acetaminophen+ le els as Perccoet and the li$e ha e this in"redient% Studies show that urine tox screens rarely help% 7arcan &nalaxone+ can help but the hal# li#e is too short #or most in"estions% 7o .=> 9ou can "i e this by intranasal or inhalation routes, but not orally &althou"h there ha e been studies in the past that trans buccal wor$s+% &7E84 3?)&2+1/?+ . would exercise extra caution with methadone as the bio absorption is erratic and these patients can crash and burn many hours later% TA2E '34E 4ESSA5E6 7o tox screens% 7arcan may ha e to been "i en by continuous e##usions% 0o not #or"et #entanyl patches as a source o# opioid 30% @e loo$

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into the media this month- Tabloid headlines- Aet1s "et

started 3) .# you are a lon" time reader o# E4B, you $now . lo e the wor$ o# Paul 4ari$, and .CB "uy that was at Alle"heny 5eneral and now is at East =ir"inia% 'e did a metaanalysis and #ound that new e idence seems to con#irm that i# your patient is not obese D the in#ection rates o# #emoral ersus .8 ersus SC C=Ps are about the same% &CC4 /0&*+2,2*+ This is contrary to
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"uidleines, and it is a meta analysis- which may not be worth much, but . thin$ it a least opens the door% TA2E '34E 4ESSA5E <emoral C=PS may not be more in#ection causin"%

4) E4B "oes to 2) countries and it is possible that you ha e

camels roamin" around your country or somethin" similar that drin$s a lot be#ore "oin" to wor$% 9es, you BSA "uysthere are camels in AriEona #rom a #ailed military experiment
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#orm lon" a"o% Camels are not pleasant animals% They bite, they spit and they can pic$ you up and throw you% .n:uries are usually se ere, and these animals are particularly disa"reeable &and dan"erous+ durin" matin" season% &.n:ury /3&-+1?1)+% @orth notin" that all in:ured patients were males and that they only saw 33 patients in six years, but that could be re#erral bias% Another interestin" point D and this isn1t meant as an insult- &camel :oc$ey is consider dero"atory+ but 12 percent were actually camel :oc$eys and all o# these children D and this may explain the se erity o# in:uries TA2E

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'34E 4ESA5E6 0on1t marry a camel- you are as$in" #or

trouble

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5) T(AA.- some re iew and new thin"s% @hat is T(AA. you as$>

.t is trans#usion related acute lun" in:ury% There are ris$ #actors #or this- li er transplant patients, alcohol abuse, shoc$, hyper$alemia, patients "ettin" whole blood and multiple trans#usions, and those with anti 'AA and anti '7A type blood& not sure i# your patient has this> As$ your resident ampire D he is sure to $now+ Spea$in" o# ampires- here is a picture o# 5rand pa- who

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played him and on what series> .nterestin"ly enou"h D #emale blood also seems to cause more T(AA. so be care#ul about "i in" "irl blood to these other patients with ris$s &why is this> Pre ious auotantibodies>+ @hat are the sympthoms> dyspnea, tachycardia hypoxemia, #e er-FG- and most importantly D pulmonary in#iltrates that are not C'<% Treatment is supporti e and EC43% &Crit Care Clinics 2*&3+3?3+% TA2E '34E 4ESSA5E6 T(AA. has ris$

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#actors so please be care#ul when you "i e blood and loo$ #or

shortness o# breath 6) .mportant point here% . wor$ed in a place where you could not ta$e blood cultures i# the patient was bein" dischar"ed% . wor$ed in places where you too$ blood cultures on all patients- -howe er . ne er wor$ed at a place where you too$ them on selected patients e en i# they had #e er% 3ur pals in .4 li$e them on all #e ers- but indeed- i# you do not ha e ri"or or S.(S criteria- they may not be too help#ul% Cellulitis and
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pneumonia lead the way in bein" #utile to ta$e blood cultures, where as septic shoc$ is more use#ul D ob iously% This soon turns out to be a political stru""le between us and .4 but . always tell my residents- - i# you are "oin" to ta$e a blood culture on penumonia then x ray his shoulder too- because you ne er i# it is not bro$en% 'ow do . $now it isn1t> ;ecause it isn1t% Period! & 8A4A 30*&,+,02+ TA2E '34E 4ESSA5E6 Cellulitis, youn" BT.s pneumonia- do not bother with blood

cultures
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7) Clinical pearls in dermatolo"y- are they $iddin"> @ho the

hec$ understands derm> 8ust "i e it some Aatin name, "i e a steroid cream and send them #or a biopsy% 7o, really, here are their pearls- "ood luc$H (ecurrent erythema multi#ormeshould ma$e you thin$ o# a 'S= in#ection D "i e them acylco ir% Strep throat can cause a rash that loo$s li$e red drops% This is not a dru" reaction but rather "uttate psoriasis which the strep causes to exacerbate% Phototherapy may be enou"h% 'ard s$in in the nec$ area- i# the patient has 04, paraprotinemia and strep in#ections- thin$ scleroderma% 7ow here is the part o# this para"raph to i"nore% (eally . mean it% 9ou can also see scleroderma in multiple myeloma, hyperparathyroidism, S:or"en1s , insulinoma, rheumatoid, and '.=% 3ther diabetes s$in disorders6 candida, diabetic dermopathy &brown spots+, diabetic bullae, necrobiosis lipoidica, acanthosis ni"ra, insulin dystrophy and xanthoma% 5ood "rie#- who cares> &4ayo Clinic Proc *)&)+ ?-,+ TA2 E'34E 4ESSA5E6 9ou aren1t "oin" to catch these rashes, but

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$eep in mind the thin"s that "o with them

8) 9ou thou"ht you should s$ip the last para"raph- boy D this is

really "oin" to put you sleep% P alues really are not that "ood% They can be in#luenced by many thin"s% <irst o# all D what is a p alue> This is measure o# how much the data obtained does not match with the null hypothesis% Bsually less than 0%0, is considered bein" no correlation with the null hypothesis% 'owe er, multiple hypotheses, data dred"in"
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&"oin" bac$ to the data and tryin" too extract conclusions #rom the data when the experiment wasn1t desi"ned #or this purpose+ small and lar"e sample siEes can exa""erate the results% .# the null hypothesis is erroneous or ridiculous, the p alue loses its alue% 9ou $now what is much better> Con#idence inter als- is the -,I chance the true data point occurs in between these two alues Dis the best correlation% &3steoarth Cart 20&*+ *0,+

This is a chart #rom the article that will help you understand the con#idence inter al TA2E '34E 4ESSA5E6 Con#idence
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inter als are more reliable than p alues% 3h 9A@7

9) 3h, . do not $now- why are you e en as$in" me> . do li$e

bashin" PP.s and we do $now they cause calcium to be poorly absorbed resultin" in more #ractures% . "uess the same could be said #or ma"nesium and indeed this study says that% & Aliment Pharm T'er 3?&,+/0,+% 'owe er, it could ta$e anywhere between 1/ days and 13 years o# therapy to occur and resol es #ast upon discontinuation o# the therapy% .n addition this is a meta analysis o# small studies and as always
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the Juestion is D are these studies comparable and where they controlled% As most o# these were case reports . do not $now i# you can conclude much, but what . would say is- use PP.s #or short term and "i e those '2 bloc$ers another chance% TA2E '34E 4ESSA5E6 PP.s may cause

hypoma"nesiumia 10) 8ust a bone #or our naturalists out there% Colds in $ids- we $now that 3TC and prescription cold medicines do not wor$ andGor ha e serious side e##ects% Echinacea and inhaled steroids also do not wor$% =apor rubs, Einc &maybe- we
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discussed this in the past+, buc$wheat honey and "ermanium extract seem to help symptoms% Pre ention D you can use probiotics, Einc, saline washes and the herbal prep ChiEu$it &contains Echinacea, propilis and itamin C+% .n adults none o# these really are that e##ecti e althou"h "arlic may reduce the incidence o# colds &maybe because e eryone who is sic$ will stay away #rom you+ 'and washin" will reduce the spread o# "erms &Am <am Phy *?1&2+1,3+ .# you as$ me- none o# this is too impressi e except hand washin"% TA2E '34E 4ESSA5E6 @ash your hands to be B(. cold #ree% 3n a related sub:ect- the mean cou"h duration in a B(. is 1* days D lon" a#ter the patient #eels better already% D Please do not treat these #ol$s with antibiotics% &Ann <am 4ed 11&1+,+ Another bone #or my tree bar$ eatin" doctors- they did a multi centered, randomiEed blinded study o# acupuncture in low bac$ pain and it was no better than placebo &Pain 1,3&-+1**3+% Could it wor$ #or somethin" else> 7ot sure as low bac$ painers are

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tou"h cases in any cases TA2E '34E 4ESSA5E 6 Acupuncture

doesn1t wor$ #or A;P 11) 9ou can reduce post AP headache- but li$e "ood psychiatristyou ha e to want to% .n this Juestionnaire &. $now, . $now D only ,1I responded+ most did not use atruamatic needles and most used bi""er needles% 4any- //I still recommend bedrest #or a prescribed period o# time and others used
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anal"esics, #luid and ca##eine none o# which has been shown to really help% 9es ca##eine does help a little, but the blood patch is the real treatment% &0an 4ed ;ull ,-&)?+A//*3+ TA2E '34E 4ESSA5E6 @e can do more to reduce post AP headache and "i e reasonable treatments #or it% @e :ust must "et e eryone to read Deither the 0anish 4edical ;ulletin or E4B% .n my opinion- you are better o## with the #ormer%

Especially i# you li$e blondes% 12) And now let1s tra el a little north to iew some more blondes in this Swedish study% They too$ all these women with pylo and "a e them either two wee$s or one wee$ o# Cipro% 5uess what> Se en days wor$ed :ust as well as 1/ &Aancet 3*0&-*/0+/?/+% Couldn1t #ind much wron" with this study, and we do $now that lon" durations o# antibiotics :ust increase
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resistance- This $ind o# reminds me o# ;AS- hit them hard and #ast% 4y Juestion is D do these #ol$s D i# they do not loo$ terrible- really need to be admitted since treatment was oral> Seems #or the literature that the answer is- no% 3# courseperhaps se en days may be too much as well% TA2E '34E 4ESSA5E6 9ou can "i e oral treatment #or pylo #or se en days and that is enou"h% Spea$in" o# blondes and Swedes- do you reco"niEe this si"nin" "roup who cran$ed out 0ancin" Kueen, . do . do . do, <ernando, and S3S%

13) . certainly use dexamethasone #or mi"raines that come to me-

but they only wor$ in 10I o# patients D perhaps some more in hi"her doses% .t is howe er, well tolerated &Post 5rad 4ed
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12/&3+110+ 'owe er, . do not belie e this wor$s on the short term, and this all depends how lon" the patients were #ollowed% 'owe er, a similar metaanalysis AE4 did bac$ in 200* &1,&12+1,,3+ was more optimistic% A randomiEed althou"h small trial in 2011 #ound thou"h that it did not wor$ &8E4 /0&/+ /?3+ but a"ain there may ha e not been enou"h #ollow up% TA2E '34E 4E4SA5E6 0examethasone is not that "reat #or mi"raines, but it is well tolerated% 4y experience is that it does wor$, and the studies are not "reat%

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14) 9es, a de#inite maybe- a#ter all, these are orthopedists writin"

these articles% .n cla icle #racturesL $ids always remodeled well, adults a lot less- in any case there is a bi" mo ement now to sur"ically #ix displaced #ractures especially in adolescents & 8 Am Acad 3rtho Sur" 20&*+/-*+ Are these :ust sur"ery happy orthos> 'ard to say% 4alunion is #or real but is it a #unctional problem> 'ow much displacement> 4y ad iceconsult% TA2E '34E 4ESSA5E6 Cla icle #racture which are displaced may bene#it #rom sur"ical repair- who "ets an

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operation isn1t clear%

15) .n my shop we are expected to start tica"elor D this stu## is

supposed to reduce cardiac death and 4.% There were si"ni#icant Juestions about the e##icacy and the sa#ety o# this dru" &it is blac$ boxed in the BSA+ &especially the PAAT3 trial+
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and as such the statistical re iewer and the cross discipline leader o# the re iew team recommended a"ainst <0A appro al% &Cardiolo"y 122&3+1//+ @hy it "ot appro ed is a "ood Juestion and may be an ethical one as well &industry pressure>+ but why should we EPs "i e such a dru" with a bloc$ box #or bleedin" when it :ust may not be better than clopid"rel> TA2E '34E4ESS5E6 ;rillinta- when compared to Pla ix- doesn1t shine

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16) 9ou should ha e $nown this% ;enEos really ha e #ew

indications other than #or seiEures% 4ood disorders and anxiety D maybe, but SS(.s are better in the lon" term and in the short term clotiapine wor$s well% ;enEos are also not the best bet #or sedation &. li$e propo#ol+ and also not #or intubated patients% =alium seems to be immunosuppressi e, and has a relati ely lon" hal# li#e &don1t let them #ool you- so does midaEolam D due to #at redistribution+% 3 ersedation and undersedation are common and benEos cause a lot o# delirium% They wea$en respiratory muscles and increase .CB time% Alternati es> (emi#entanil, dexedotmidine and propo#ol do not cause delirium and ha e shorter hal# li#es & Chest 1/2&2+2*1+% TA2E '34E 4ESSA5E6 ;enEos are not really the

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best bet #or a lot o# thin"s we used them #or in the past

1)+ @ill mention this one last time D another randomiEed study that shows that antibiotics are the way to "o #or appendicitis% Sure 1G/ o# the patients in this study ended up "o to the 3( and another 11I had a recurrence within one year, but "i in" antibiotics is much sa#er than operations

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