Category Archives: EM in the News

Public health for adrenaline junkies

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Public health is associated with the least interesting courses of medical school (epidemiology and biostatistics). It has been linked to ED frequent flyers and psych hold patients (social and behavioral health). One might say it’s an integral part of vague clinical decision rules and flip-flopping society guidelines and Press-Ganey scores.

It’s also something us ED docs do every day, whether we want to or not. There’s no reason why we shouldn’t try to understand it and do it better.

Kiran and I have been developing a website dedicated to public health for ED personnel. It’s a FOAMed site. Our plan is to get it tied in with sites like EMCrit, ALiEM, LITFL, and the like. It’s still a very young project, but there’s a couple articles posted for you to glance at.

If anyone is interested in population health, there’s a ton of uncharted territory and we’d welcome the collaboration. Just let us know how you want to be involved. Also, tell your friends.

 

The Hypercoagulable Liver Failure Patient?

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Hey Guys,
Just listened to a portion of April EM:RAP (so if you’ve heard it already here’s a little repetition) and was surprised to hear their Notes from the Community Section about coagulopathy in Liver Disease, which basically informed me that many liver patients are at just a high of risk of thrombosis as they are of bleeding.

3 Articles were referenced:
– Tripodi A, Mannucci PM. The coagulopathy of chronic
liver disease. N Engl J Med. 2011 Jul 14;365(2):147-56.
– Villanueva C et al. Transfusion strategies for acute upper gastrointestinal bleeding. N Engl J Med. 2013 Jan 3;368(1):11-21.
– DeLoughery TG et al. Invasive line placement in critically ill patients: do hemostatic defects matter? Transfusion. 1996 Sep;36(9):827-31.

Summary:
– The liver makes both procoagulant and anti-coagulant proteins which can be actually reduced close to equally rendering the patient basically in equilibrium (thus not so hypercoagulable).
– No study has shown that coagulation defects predict issues with procedures (but the experience of the clinician performing the procedure does).
– INR is not standardized in Liver Failure patients (like it is with Warfarin) and thus is not that helpful.
– PT & PTT may also not be helpful in patients with liver failure (due to the variability of loss of clotting factors)
**Fibrinogen may be low in liver failure patients, and you may consider replacement of this with Cryoprecipitate (10 units of Cryo increases the Fibrinogen by 100mg/dl).
– Raising intravascular volume with pRBCs may make them bleed more.

For the full references & discussion see the EM:RAP written summary. Perhaps this is something we should discuss with our GI colleagues and/or MICU people. Any thoughts?

FOAMed and Social Media in Education

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At the CORD Academic Assembly there was a lot of talk about FOAMed and Social Media. I am on the social media committee with CORD and we have some informative projects on the horizon.

Here is a blog post detailing some of the FOAMed workshop with some How-To information.

Then Joe Lex and Nicholas Genes posted PRO and CON articles on the question “Is FOAMed essential to Emergency Medicine education.”

Not long articles, good to be at the forefront of these changes. And good discussion on the pluses and minuses of FOAMed

March EM:RAP Summary

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Hey Guys,
Just some things I learned on EM:RAP this month, and since I’m on admin thought I would post a few things.

The DRE (not the rapper Dr. Dre): from the Fingers & Foley’s section on EM:RAP; reviewed Esposito TJ et al. Reasons to omit digital rectal exam in trauma patients: no fingers, no rectum, no useful additional information. J Trauma. 2005. They had 512 trauma patients at a Level I Trauma Center. “the negative predictive value of both the rectal exam and other clinical indicators was very high: 99%. However if the other clinical indicators missed the injury, so did the rectal exam. It didn’t add any information”
Basically showed added value of a rectal exam to be very minimal, and that ROUTINE RECTAL EXAM IS NOT RECOMMENDED. BTW, this is in the journal of trauma which is well-regarded amongst our surgery friends.

How to identify if patient’s contact lens is still in the eye (e.g. if patient has eye pain and feels like its still in there and can’t find it): Use Fluorescein much like you would for corneal abrasion as it will stain the contact lens as well, allowing you to find it (then you can evaluate for corneal abrasion at the same time). *keep in mind contact lens will be ruined*

Subarachnoid Hemorrhage: from an article in JAMA in Sept 2013 with 10 university affiliated Canadian EDs. Tried to come up with a decision rule for SAH and basically came up with:
The decision rule including any of age 40 years or older, neck pain or stiffness, witnessed loss of consciousness, or onset during exertion had 98.5% (95% CI, 94.6%-99.6%) sensitivity and 27.5% (95% CI, 25.6%-29.5%) specificity for SAH. Adding “thunderclap headache” (ie, instantly peaking pain) and “limited neck flexion on examination” resulted in the Ottawa SAH Rule, with 100% (95% CI, 97.2%-100.0%) sensitivity and 15.3% (95% CI, 13.8%-16.9%) specificity.
**Key points: this decision rule is more to identify high risk patients and the high risk symptoms. Sensitivity was very high, but specificity very low. Also keep in mind there are other important causes of headache to keep in mind**

Biphasic Reactions in Anaphylaxis: from Annals of Emergency Medicine in November 2013. A chart review was performed over 5 years and had ~500 pts with anaphylaxis, but also documented allergic reactions. Found biphasic reaction was extremely rare (2 cases while in the ED, and 3 out of the ED), with a rate of 0.4% while in the ED. 6% bouncebacks in the anaphylaxis group, none of which died and none of which came back in anaphylaxis. This study was limited in that it was retrospective, and there was variability in the outpatient management of these patients (unclear who was DC’d with what if any medications)
Rosen’s states corticosteroids can be helpful in reducing risks of protracted anaphylactic reaction and biphasic anaphylaxis (7-10 day course). H1 & H2 antihistamines are helpful in reducing some of the symptoms of anaphylaxis. 5-Minute Emerg Consult recommends Epi-Pen for those with anaphylaxis.
No Formal observation time has been established, though Rosen’s says 2-6 hours; with longer observation times/admission for those with prolonged reaction or requiring multiple dose epinephrine

Sorry this is so long, but I’m on Admin so thought I’d post something. Attached you’ll find the March Written Summary with all the articles they referenced. Hope this is helpful.

Dimer wins again

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Here is a post from Ryan Radecki at EM Lit of Note. His philosophy mirrors what I took from Jeff Kline the PE guru on the approach to PE workup. When you have committed to ordering a CT-PA, then get a d dimer and if NEG, CANCEL the CT. Controversial of course. But the dimer is MORE SENSITIVE than a CT. Some say the d dimer is only for “low risk” patients, but check out this study using not necessarily low risk patients.