August 9th Conference Pearls

Brought to you by: Maninder Singh and Brian Gilberti

Journal Articles That Changed My Practice (Dr. Gruber):

  • People are unlikely to publish evidence based medicine if the conclusion is fewer interventions are needed
  • “CYA” mentality affects the validity of shared decision making: move away from using percentages to absolute numbers
  • American College Radiology Manual on Contrast Media 2016: Only need a creatinine for:
    • pts >60 y/o
    • h/o renal disease
    • h/o HTN requiring meds
    • h/o DM/Metformin
  • ACR appropriateness criteria:
    • Don’t given oral contrast if SBO known/suspected (risks > benefits)
  • Intravenous contrast alone vs intravenous and oral contrast computed tomography for the diagnosis of appendicitis in adult ED patients. Kepner AM. AJMER 2012:
    • Oral contrast is only indicated for post gastric bypass or IBD
  • Outcomes after out-of-hospital cardiac arrest treated by basic vs advanced life support. Sanghavi P, et. al. JAMA Intern Med 2015:
    • No evidence that drugs help in cardiac arrest so should probably focus on compressions
  • The evil of good is better: Making the case for basic life support transport for penetrating trauma victims in an urban environment. Rappold JF. J Trauma Acute Care Surg 2015:
    • Risk of death ALS vs BLS transport odds ratio 1.8(1.1-3.1) police vs BLS 2.57(1.6-4.1);  ALS vs BLS care: OR 2.55(1.5-3)
    • Hemorrhage is most common cause of morbidity/mortality in penetrating trauma
  • Think of Doctors as Pilots:
    • A “sterile cockpit” can be useful in the ED when doing procedures that could suffer from distraction
    • A “co-pilot” can be helpful because by verbalizing the case to another provider, you can often figure out the answer or make the problem clearer
    • Mentally rehearsing procedures or resuscitations prior to shift can make them run smoother
  • Effect of Conservative vs Conventional Oxygen Therapy on Mortality Among Patients in an Intensive Care Unit: The Oxygen-ICU Randomized Clinical Trial. Girardis M. JAMA 2016:
    • PaO2 70-80 Sat 94-98% (intervention) vs Pa02 to 150 Sat 97-100%(conservative)
    • Primary outcome ICU mortality: 11% vs 20%
    • Secondary outcome: less shock, liver failure, bacteremia, time on vent (RR 0.29-0.5)
    • Evidence higher levels of FiO2 negatively affect organ function, increase free radicals, microcirculation
  • Using venous blood gas analysis in the assessment of COPD exacerbations: a prospective cohort study. McKeever, et. Al. Thorax 2016:
    • As compared to an ABG, VBG usually has a lower pH but higher HCO3/pCO2
    • Venous pCO2<45 reliably excused clinically significant hypercarbia (arterial pCO2>50)
    • Pulse Ox on room air > 97% mean pCO2 <50
    • Good correlation between pulse ox and pO2 when pulse ox > 80% (on RA)
  • 3 ways of determining hypercarbia (without doing an ABG):
    • If VBG pCO2<45, patient is not hypercarbic
    • If VBG pH>7.34, patient is not hypercarbic
    • If pulse oxygenation on RA > 95%, patient is not hypercarbic
  • Effect of Blood Pressure Lowering in Early Ischemic Stroke: Meta-Analysis. Lee, et. Al. Stoke 2015:
    • Lowering BP in early ischemic stroke had no effect on death/dependency at 3 months
    • Didn’t influence recurrent vascular events
  • Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. Qureshi, et. Al. NEJM 2016:
    • Intensive reduction in SBP in ICH to 110-140 rather than the standard 140-170 doesn’t decrease death or disability
  • Platelet Transfusion Versus Standard Care After Acute Stroke due to Spontaneous Cerebral Hemorrhage Associated with Antiplatelet Therapy (PATCH): A Randomized, Open-Label, Phase 3 Trial. Baharoglu, et al. Lancet 2016:
    • Platelet transfusion in pts with acute ICH taking antiplatelet therapy revealed increased mortality and dependence at 3 months
  • Video laryngoscopy vs. direct laryngoscopy: Which should be chosen for endotracheal intubation during cardiopulmonary resuscitation? A prospective randomized controlled study of experienced intubators. Kim, et al. Resuscitation 2016:
    • Direct Laryngoscopy same success rate as video laryngoscopy but longer duration of CPR interruption (10 seconds)
  • Safety of the Peripheral Administration of Vasopressor Agents. Lewis et al. J Intensive Care Medicine 2017:
    • Short term peripheral vasopressors are safe
    • Recommendation: Should use in pts with contraindications for central line
  • Early neurologic examination is not reliable for prognostication in post-cardiac arrest patients who undergo therapeutic hypothermia. Merrill et al. Am J Emerg Med 2016
  • Will This Hemodynamically Unstable Patient Respond to a Bolus of Intravenous Fluids? Bentzer, et al JAMA 2016:
    • Passive leg raise most accurate predictor of fluid responsiveness but you need a method to measure cardiac output.
    • If the CO does not increase with passive leg raising, the patient is unlikely to be fluid responsive.
  • Postural modification to the standard Valsalva manoeuvre for emergency treatment of supraventricular tachycardias (REVERT): a randomised controlled trial. Appelboam, et al. Lancet 2016:
  • Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial. Pickard, et al. Lancet 2015:
    • Rates of spontaneous stone passage: Flomax 81%; Nifedipine 81%; Placebo 80%
    • No difference in analgesic use or health status
    • May have benefit in larger stones > 5mm
  • Can Sexual Intercourse Be an Alternative Therapy for Distal Ureteral Stones? A Prospective, Randomized, Controlled Study. Doluoglu, et al. Urology 2015:
    • Compared (a) Sex 3-4x/week to (b) Flomax to (c) Nothing
    • Stone size (a) 4.7mm, (b) 5.0mm, (c) 4.9mm, respectively
    • Stone expulsion at 2 weeks: (a) 84%, (b) 48%, (c) 35%, respectively
    • Time to expulsion: (a) 10 days, (b) 16.6 days, (c) 18 days, respectively
  • Emergency Department Patients with Atrial Fibrillation or Flutter and an Acute Underlying Medical Illness May Not Benefit from Attempts to Control Rate or Rhythm. Scheuermeyer et al. Ann emerg Med 2015:
    • 281 patients with no rate control VS 135 with rate control
    • 3 major adverse events with no rate control VS 19 in patients with rate control
    • Found ACS in 11% (45/416), ADHF in 28% and Sepsis in 32%
    • Rate control can often wait, if patient is not hypotensive
    • Think about why are they in RVR in the first place– dehydration, underlying sepsis (especially in older patients who may not be febrile or have an elevated WBC), GI bleed, CHF, etc
  • Trimethoprim-Sulfamethoxazole versus Placebo for Uncomplicated Skin Abscess. Talan, et al. NEJM 2016:
    • MRSA in 45%
    • Cure Rate: 93% in Bactrim VS 86% in Placebo
    • Decreased repeat I&D and new skin infections at 14 and 56 days in Bactrim group
    • First study to show short term benefit with respect to primary lesion
    • IDSA recommends antibiotics if fever, hypothermia<36C, RR>24, Tachycardic>90, WBC>12k, multiple lesions, high risk/painful areas (hands, genitals), very old/young, and not amenable to complete I&D
  • Top Ten Myths Regarding the Diagnosis and Treatment of Urinary Tract Infections. Schulz. JEM 2016:
    • Myth: UTI if bacteria in urine
      • UTI is clinical diagnosis
      • Asymptomatic bacteria leads to overdiagnosis
      • Dysuria + frequency in the absence of vaginal sx = UTI w/o needing UA
    • Myth: Urine is cloudy and smells bed so patient has a UTI
      • Foul smelling urine usually dependent on hydration status and concentration of urea in urine
      • 100 females had urine tested by reading newspaper through urine sample and found sensitivity of 13.3%, specificity of 96.5%, PPV of 40% and NPV of 86.3%.
    • Myth: Sample is reliable if >5 squamous epithelial cell/LPF but the culture is positive
      • Need to repeat urine sample- a good specimen has <5 squamous epithelial cells/LPF
    • Myth: Positive Leukocyte esterase should be treated
      • Leuk Esterase is sensitive not specific
      • Urine symptoms but negative leuk esterase- think urethritis/vaginitis/STD
      • Negative LE and Nitrate- 88% NPV
    • Myth: Pyuria is only present on UA if UTI
      • Also present with hematuria, dehydration, STI, non infections causes (AKI, appendicitis, diverticulitis, advanced age)
      • Neutropenic/Leukopenic patients- urine WBCs may be artificially low
    • Myth: Positive nitrates means UTI
      • Nitrates predict bacteriuria but if not clinical sx, likely associated with colonization
      • Nitrates aren’t produced by S. Saprophyticus, Pseudomonas, or Enterococci so no nitrates does not exclude UTI
    • Myth: Bacteriuria and Pyuria in patient with indwelling foley indicate infection
      • Almost all indwelling foleys colonized w/in 2 weeks with 2-5 organisms
      • Only treat if patient has new symptoms (fever, pain, etc)
      • Get fresh catharized UA- never from the bag
    • Myth: Elderly patient confusion is usually due to UTI
      • UTI should be diagnosis of exclusion
      • Do not prematurely close case and miss important diagnosis
      • Treat only if localizing urinary symptoms are present (if accurate historian)
    • Myth: Patients with bacteriuria will progress to a UTI so should treat
      • Bacteriuria and pyuria in elderly is expected
      • Individually pyuria, leuk esterase or nitrate not an indication for treatment. Exceptions: pregnant or any urologic procedure with bleeding (stenting, etc)
      • Younger women with recurrent UTI- may be protective against more pathogenic organisms
    • Myth: Presence of Yeast/Candida with indwelling foley means candida UTI
      • Candiduria has low incidence of systemic complications (except in high risk transplant recipients, immunocompromised, etc)
      • Think about vaginal/external contamination
    • Positive urine cultures can still be contaminant or asymptomatic bacteriuria
    • Treat young women with suspected UTI, regardless of UA
    • Get U/A culture if pregnant, not responding to antibiotics, recurrent UTI, suspect pyelo, immunocompromised or multiple allergies
    • Imaging is not routinely required in stable patients suspected of pyelo except if h/o nephrolithiasis, severe pain, severe sepsis, renal insufficiency (GFR <40), or unsure

Endocarditis (Dr. McCormack):

  • Always send 3 blood cultures if suspecting endocarditis
  • Infective Endocarditis Microorganisms: Staphylococcus Aureus, Viridans Streptococci, Streptococcus Gallolyticus, HACEK (Haemophilus, Aggregatibacter, Cardiobacterium, Eikenella, Kingella) organisms, or community-acquired enterococci (from UpToDate)

How to read a CXR (Dr. Sweeting):

  • RIP-ABCDE Method
  • Rotation- if one clavicular head is closer to midline, patient rotate to opposite direction
  • Inspiration- count number of ribs visible
  • Penetration- look at spinal body
  • Airway- check for tracheal deviation, foreign bodies, ETT position, or swelling
  • Bones- check ribs, vertebrae, clavicle, scapula and sternum
  • Cardiac- check size and any mediastinal abnormalities
  • Diaphragm- check hemidiaphragms position/shape, free air and costophrenic angles
  • Everything Else- lungs for consolidations/PTX, hilum for adenopathy, great vessels, and soft tissues for swelling, air, or devices

Dental Emergencies (Dr. Shibuya)

  • https://www.youtube.com/watch?v=bkh1Ru6jwew
  • In a dental fracture, the exposed tissue needs to be covered with temporary dental cement to prevent pulp infection.
  • If a tooth is avulsed, place it in an isontic solution immediately and replace it in the socket as soon as possible.

Posterior/Right Ventricular MI (Dr. Somberg)

  • https://www.youtube.com/watch?v=m9BY3HNfWCE
  • Suspect and look for posterior MI when you see large ST depressions in V1-V3.
  • Always consider right ventricular MI in any inferior STEMI- give fluids, avoid nitro, and look out for bradyarrhythmias.

SAH as STEMI (Dr. Sun)

  • https://www.youtube.com/watch?v=caRvYmxAW_M
  • Important to rule out other causes of ST elevations on EKG
  • Fatal if SAH as treatment for STEMI is opposite of what you want (anticoagulation) and delay in proper treatment (if patient sent to cath lab instead of OR)

Epistaxis (Dr. Walker)

Cardiac Syncope (Dr. Simich)

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