2012-13 Recent Literature Update for Emergency Medicine: Panacek Disclosures: None

Panacek: Recent lit update
Recent Literature Update
for Emergency Medicine:
Panacek Disclosures: None
No relevant financial relationships
pertaining to this lecture
Edward A. Panacek, MD, MPH
UC Davis Medical Center
Maui conference: 2012
The overwhelming amount of
information in medicine
Your job:
commit yourself
Each year:
 More than 3,000 biomedical journals are
 The FDA approves more than 500 new or
updated drugs and 3000 medical devices
Even if you only try to keep up with the 5 EM
relevant journals and JAMA and the NEJM,
you would have to read over 17 articles/day
and 1,200 pages per month
It is stated that didactic lectures have little
impact on clinical practice
That lectures are too passive for adult
learners, but surveys indicate this is the
preferred CME format for physicians
In this talk, I am asking you to
identify 2-3 things that will change
your practice
We treat tons of asthma
Which inhaled bronchodilator
regimen works best?
Panacek: Recent lit update
Continuous vs intermittent albuterol to reduce
hospital admissions in acute asthma
Gregory. AnnEmerMed.2012;60: 663
 Systematic review “snapshot” article
 20 articles reviewed. 8 RCTs included
 Continuous nebulization:
 Clearly better in severe asthma
 Also better in moderate asthma (RR= 0.64)
 No benefit in mild asthma
 No increased side effects
 NNT in mod/severe = 7 (to save admission)
PE risk increases somewhat
during pregnancy
Take home points
 NNT of 7 is very low to save something
as important as an admission.
 Continuous should become std care in
all moderate/severe asthmatics in the
 Don’t bother in the mild cases
 But even if used in all ED asthmatics, NNT = 9-12
to save an admission.
Am Thoracic Soc & Soc of Thoracic Radiology
practice guideline: Eval of PE in pregnancy
Leung. AmJRespCCM.2001;184:1200
 Also endorsed by ACOG
 Not much high level type evidence
 Recommendations:
Which test is best to order to
R/O PE in a pregnant mother?
Their algorithm
1. Avoid use of D-dimer in pregnancy
2. If any leg Sx, start with Compression U/S
If CUS is (+)  treat
3. If no leg Sx, order chest studies
Start with CXR
V/Q if CXR nl, CTA if it is not.
Am Thoracic Soc & Soc of Thoracic Radiology
practice guideline: Eval of PE in pregnancy
Other points:
 CTA is less radiation for the fetus
 But more for the mother, and particularly for
breasts with increased susceptibility
 CTA views often substd unless special dye
protocol used.
 V/Q is more radiation for the fetus
 But less total overall radiation. Starting with
perfusion portion only decreases the rads
 Less problems with substandard views than CTA
Panacek: Recent lit update
Take home points
 Avoid D-dimer tests in late pregnancy
 Can use earlier, but specificity is low.
 Why not just always start with CUS?
Critical Care
 If CXR is normal, V/Q scan is the
recommended choice
 should rarely be “indeterminate”
 CTA if you can’t get that study or if nondiagnostic
Preoxygenation and prevention of desaturation
during emergency airway management
Weingart, Levitan. AnnEmergMed. 2012;59: 165
Airway management getting
easier with new devices
 Emergency airway pts at high risk for hypoxemia
 Desat < 70%  high risk for complications
 NRB masks used poorly and often not enough
 EPs tend to rush and fail to use all their resources
Anything else we can do to
improve emergency airway
Preoxygenation and prevention of desaturation
during emergency airway management
 Higher flows of O2
 Pre-oxygenate longer (> 8 deep breaths, 3 min if able)
 Add NC flow at 15 liters, and leave it on for duration
Concept of “apneic ventilation”
Take home points
How fast does desaturation < 90% occur?
 Want less anxious intubations?
 Room air, normal lungs:
1 min
 Room air, diseased lungs
30 sec
  Pre-oxygenate better.
 NRB mask 10-15L preox
1-3 min
 Higher flow, better NRB mask O2
 Higher preox O2 admin
2-5 min
 Add in NC O2 at 5-15 L/min
 Add NC O2 5-6 L/min
4-8 min
 NC O2 at 15+ L/min
7-100 min
 Leave it on and running during the
intubation attempt(s)
Panacek: Recent lit update
Septic shock carries a 40%
mortality. Higher if not reversed
Dopamine versus norepinephrine in the Tx of
septic shock: Meta-analysis
DeBacker, Vincent. CCM. 2012;240: 725
 Individual studies show mixed results
 Meta of 11 studies ( 6 RCTS), 2768 pts
 Dopamine  increased risk death (OR 1.12)
Many pressor regimens still
being used. Which is best?
Take home points
 In 2012, dopamine should no
longer be the first choice pressor
for septic shock
 And maybe not for much else either
 Little difference in ICU or hosp LOS
 More dysrhythmias with dopamine (RR= 2.34)
Not all septic shock responds to
Then what?
Dopamine? Something else?
Cardiopulmonary effects of vasopressin with
norepinephrine in septic shock
Gordon. CHEST. 2012; 142: 593
 Post hoc analysis of VASST trial subsets
Take home points
 For septic shock;
 Not randomized.
 Avoid dopamine
 Vasopressin  lower HR, same CO
 Levophed first line pressor
 Seemed to benefit some refractory shock
 Vasopressin and epinephrine as
second line options
 Not compelling as first line pressor
 Reasonable option for refractory cases.
Panacek: Recent lit update
Comparison of IO vs CVC access in adults under
resuscitation in the ED
Leidel. Resuscitation. 2012; 83: 40
Need to fluid resuscitate the pt
Vascular access problems
 Adults, attempts at peripheral IV failed
 RCT of IO vs landmark CVC access
 IO; 50% tibial, 50% humeral; CVC: subclavian
Gown up for full sterile CVC line?
Keep trying peripheral?
U/S guided peripheral? Other?
IO vs IV during out of hospital cardiac arrest
Reades. AnnEmergMed. 2011; 58: 509
 Adults, arrest, no easy peripheral IV
 3 arm RCT of IO vs peripheral access
 IO: randomized to tibial vs humerus
IO: tibial
4.6 min
IO: humerus
7.0 min
Periph IV
8 min.
Humeral IO lines dislodged the most (20%)
Fluids given fastest via peripheral IV
Delayed complications not measured
Cardiac arrest.
Shock first? CPR first?
AHA CPR guidelines have flipflopped on this between the last
3 updated recommendations
2 min
8 min.
 No major complications in either group
Take home points
 IO lines not just for Peds anymore !
 Should be considered as second
line if easy peripheral access
 Proximal tibia better than humerus
Earlier vs. later rhythm analysis in pts with out of
hospital cardiac arrest
Steill. NEJM. 2011; 365: 787
 ROC group multicenter RCT. US & Canada
 9.983 adults, nontraumatic, arrest
 30-60 sec CPR then analyze and shock vs. 3
min of CPR before analysis
 Good neuro @ hosp D/C= 5.9% in each group
 Time to analysis: 42 sec vs 180 sec.
 No diff in 2nd outocmes (ROSC, survival, etc.)
Panacek: Recent lit update
Take home points
 Early vs late rhythm analysis
doesn’t matter
 But either way, do immediate CPR
and continue CPR until ready for
analysis and shock!
 BTW, the 2010 AHA-ILCOR guidelines noted
inconsistent evidence
Duration of CPR efforts and survival after inhospital cardiac arrest: an observational study
Goldberger. Lancet. 2012. S0140
 Retrospective, nested registry study
 ROSC pts had shorter CPR ( 12 vs. 20 min)
 Avg resuscitation time = 16 min overall
 However, hospitals with longest quartile of
CPR time (25 min) had best outcomes
 RR= 1.12
 Not an RCT, possible confounders
Survival and good outcome
decrease with longer CPR
How long to continue CPR?
Even if monitor shows a
rhythm, quit once clock hits…?
Take home points
 This study does not prove that
longer is better.
 But it does support that longer may
not be worse.
 Tailor duration of CPR more to the
individual pt and less to the clock
 No evidence of worse neuro outcomes if longer CPR
Infectious Diseases
1/3 of teenage females will get a
UTI by age 20
How to address this?
Panacek: Recent lit update
Adolescent female with urinary Sx: Dx challenge
Prentiss. PedEmergCare.2011; 27: 789
 Both UTIs and STIs become common in
females by age 20. The Sx can overlap
Adolescent female with urinary Sx: Dx challenge
 UTI Dx in 57%, STI in 9%, both in 6%
 Physician clinical impression accuracy:
 Prospective, 211 females, 13-19yo, UTI Sx
 UTI: 90% sensitive, 46% specific, 71% overall
 Asked physicians for clinical impression
 STI: 47% “
 Then used a “two specimen” technique
 “Dirty” catch urine for STI (nucleic acid amplification)
 “Clean” catch sent for U/A and C/S.
, 83%
 Both: very poor performance
 Significant rates of over and under Dx of either
 Conclusions:
 clinical judgment is poor
 Test for both
Take home points
 Beware of missed STIs in 13-19 yoF
STIs are an important public
health issue, with significant
potential morbidity
 Double collection technique needs
validation in another study
 Don’t trust clinical judgment alone
 But could be brilliant
 Would miss trichomonas and candida
Expedited partner Tx in management of GC &
chlamydia by OB-Gyn
Committee opinion. OB & Gyn. 2011; 118: 761
Professional ACOG comm recommendation:
 Tx of women with STIs should include Tx
partners also
 Ideal to have partner seen, but not required
 Decreases prevalence of STI and recurrence
 Controversial legal issues
 Permissible in 32 states, illegal in 7, 11 unclear
 Supported by the CDC
Anything the ED can do to
better treat and control?
Take home points
 STIs at epidemic rates in many
areas and subpopulations
 3x10^6 new chlamydia cases/yr, 700,000 GC
 Tx trend is growing nationally
 CDC supports it
 Legal in most states
 Legal in CA
 Produced a “toolkit” for implementation
Panacek: Recent lit update
Therapeutic options
The acutely agitated patient !
Need to get control fast…
Boy do I miss droperidol !!
IV versed + droperidol or olanzapine for the
acutely agitated pt: MCRCT
Chan. AnnEmergMed. 2012; Sept.
 336 serve agitated adults, blinded RCT:
 IV : Droperidol 5mg or olanzapine 5 mg or placebo
 Then 2.5-5 mg versed iv immediately and prn
Results: Active drugs vs placebo:
 Both much better time to sedation
 5 min vs 10 min (HR:1.64)
 Both req’d less rescue therapy
 No effects on QTc seen
 More adverse events in versed alone group
Anxiety, panic disorder
Seems like an epidemic
Take home points
 Olanzapine seems to work about a
well and fast as droperidol
 Dosing is similar, but don’t start
with < 5 mg
 I may have a new friend !
 I’m wondering about additional
applications also ????
Efficacy and safety of alprazolam vs other
benzos in the Tx of panic disorder
Moylan. JClinPsychopharm. 2011; 31: 647
 Guidelines rec SSRI (or TCAs) as 1st Tx for
panic attack
 Benzos are 2nd line. Xanax is the most prescribed.
Xanax is harder for some pts to
get, more expensive than other
benzos. What to use?
 Meta-analysis of 8 RCTs comparing
benzos (5 different agents)
 No difference in freq or severity of attacks
 No difference in complications
Panacek: Recent lit update
Take home points
 For panic and anxiety Tx, little
difference between the benzos.
 Other literature supports higher rates of
addiction/problems to xanax
Akasthesia is rather common
Can limit use of antiemetics
 Higher rebound anxiety, withdrawal, ODs
 some due to shorter ½ life issues
 Authors quote: “ physicians are the
greatest (inappropriate) facilitators of
alprazolam”……….. I have stopped
Slow infusion of metoclopromide does not affect
efficacy but reduces akasthesia and sedation
Tura. EmergMedJ. 2012;29: 108
 25% of pts can get akasthesia with reglan
 140 adults, N/V, blinded RCT
 Reglan 10mg IV, over 2 min vs 15 minutes
 No difference between groups on N/V effect
 At 15 min or at 1 hr
 Much less complications with slow infusion
We have few anti-emetics as it
is, anything that we can do
about this?
Take home points
 You can seriously decrease the
problems of giving IV reglan by
slow infusion (over 15 minutes)
 Change your orders
 Change your ED practices
 Akasthesia less (7% vs 26%)
 Sedation less (14.5% vs 27.5%)
Lots of N/V in the ED
Lots of anti-emetics,
if you can get them !
RCT of ondansetron vs. prochlorperazine
in adults in the ED.
Patka. WestJEM. 2011; 12: 1.
 64 adults, vomiting, DB-RCT, IV Tx
 Zofran 4 mg IV vs compazine 10mg IV
 Most common Dx’s: flu, gastroenteritis
Zofran is newest, best,
 Compazine was better:
 Less recurrent vomiting 3% vs 22%
 Lower nausea scores(100mm) at 1 & 2 hrs (25 vs 44)
 Sedation scores similar.
 Compazine  more akasthesia (9 vs 3 5)
Panacek: Recent lit update
RCT of ondansetron, Reglan and promethazine
in adults with nausea in the ED
Barrett, Storrow, slovis. AmJEM. 2011; 29: 247
 163 adults, nausea, 3 arm RCT:
 IV Zofran 4 mg vs Reglan 10mg vs phenergan 12.5
vs placebo
 All given 500 ml IV saline
 Nausea measured on 100mm VAS scale.
Take home points
 Zofran may be newer and fancier, but is
not better than older anti-emetics
 Probably not even as good as the old
standards of prochlorperazine, etc.
 I miss compazine !
 Best decrease in nausea scores with Reglan (-29) and
phenergan (-30)
 Zofran only modestly better (-22) than placebo (-16)
Careful about epinephrine
injections and ischemia in
selected vascular beds
Fingers, toes, penis, nose…
Six years of epinephrine digital injections:
Absence of significant local or systemic effects
Muck. AnnEmergMed. 2010;56: 275
 Natural experiment of accidental injections
with epi-pens
 6 poison centers, 6 yrs, 365 cases
 213 accidental digital injections, 127 with F/U
 23% rec’d vasodilatory Tx, mostly just empiric
 4 had evidence of ischemia, all improved with Tx
 None had significant systemic symptoms
 100% had full recovery
Take home points
 Concerns about use of epinephrine in
the hand are excessive.
 Hand surgeons routinely use lidocaine
with epi in the hand
Surgical / Trauma
 Original prohibitions resulted from
intra-arterial injections
 Avoid that and use is fine
Panacek: Recent lit update
Needle decompression of chest and
placement of small bore chest tubes
often recommended to be in the 2nd
ICS, mid-clavicular line
Why there?
What is the reasoning?
Poke in the ribs: What is the best location for
catheter thoracostomy?
 Wall at AAL averages >50% thinner than MCL
 Averaged 13 mm thinner
 Women were thicker at all sites than men
 Chest wall thickness  with each quartile BMI
 Std 5cm catheters would fail in 43% at MCL
 Would fail in only 17% at AAL
 Failure rate in MCL approaches 100% in
highest BMI pts
Poke in the ribs: What is the best location for
catheter thoracostomy?
Inaba. Arch Surg. 2012.
 ACS recommends needle decompression of
possible tension PNTX with 5 cm catheter in
the 2nd ICS, MCL
 120 trauma pts undergoing Chest CT
 Stratified into quartiles by BMI
 Measured Chest wall thickness in 2nd ICS,
MCL and 5th ICS, AAL
 Calculated how often a 5 cm catheter would
reach the pleural space.
Take home points
 Consistent with prior cadaver studies
using actual 5 cm needles
 Reflects growing BMI in the public
 Results likely also apply to small bore
chest tube placements for spontaneous
 In thin pts, MCL likely still OK.
 In others, move to the 5th ICS, AAL
BET 2: Finger fracture
Distal phalanx fracture with finger
laceration injury, +/- nail bed injury…
Wilkinson. Emerg Med J. 2011; 28: 441.
 Are Abx req’d to prevent osteomyelitis in
compound fxs of the distal phalanx?
 Systematic review. 4 RCTs.
 No difference in infection rates regardless
of Abx. None developed osteomyelitis
Considered open.
 Some cellulitis seen, but same rates with Abx.
So give Abx, right?
 All studies used good irrigation,
debridement practices.
Panacek: Recent lit update
Take home points
 Abx not required for most open
fractures of the distal phalanx
 Osteomyelitis never seen
 Good local wound care essential
Persistent serious hip pain post
trauma. Plain films negative.
What best to order next?
CT or MRI or ?
Occult hip fractures: Which imaging modality is
best? Does it matter?
Hakkanian, Hendey. JEM. 2012; 43: 303
 Advanced imaging indicated if plain films neg
 Prior studies  occult fractures in ~4%
 CT reputation is very good for bone pathology
 235 adults, > 60, hip pain, fracture
 10% were occult, not seen on plain films
Take home points
 CT may generally be very good for
bone pathology and detail, but..
 MRI definitely wins for picking up
occult fractures of the hip, pelvis
 Likely true for elsewhere also.
 MRI found 4 missed by CT (2% of all pts)
Acute abdominal pain.
LFTs, lipase, UA, etc
And abdominal films…?
Panacek: Recent lit update
The role of plain radiograps in pts with acute
abdominal pain in the ED.
Van Randen. Am J Emerg Med. 2011; 29:582
 Prospective, multi-center study, 1,101 pts
 Adults with non-trauma AP > 2 hours, < 5 days
Take home points
 Abdominal films are a hold-over from
the pre-CT era
 All got 2 view abdomen (flat and upright)
 Currently are rarely indicated.
 Treating MDs listed likely Dx and confidence score
before and after the films
 Still over-ordered
 All pts got advanced imaging (U/S or CT)
 “Possible” reasons to order:
 Quickly prove free air in unstable pt
 Final Dx compared to preliminary ones
 Quickly find megacolon, etc, to  decompression
 Results: No benefit
 Prove to pt/family that pt is FOS and needs bowel
care regimen
 Pre Dx agreed with final 49%, post Dx agreed 50%
Variation in use of head CT by emergency
We live in the CT era
Prevedello. Am J Med. 2012; 125: 356.
 Retro chart review, single large urban ED
 55, 286 pts reviewed for 38 ED attendings
 4919 HD-CTs ordered
How much do physicians vary
in their CT ordering frequency
and patterns?
Results: Huge variability…. How bad?
 Unadjusted order rates range: 4-17%
 Adjusted rates: 6.5-13.5%
 Non-Trm HA unadjusted rates: 15 – 62%
adjusted rates: 21 – 60%
Take home points
 Huge differences are hard to explain
 Did not examine outcome differences
 CMS recently approved a measure to
track ED HD-CT ordering for nontraumatic HAs
 Unlikely that this amount of variability
will continue to be acceptable to payers
Panacek: Recent lit update
Rhogam for Rh(-) females with
pregnancy related bleeding
Emergency uncrossed transfusion effect on
blood type alloantibodies
Miraflor. J Trauma. 2012; 72: 48
 O(-) is universal donor, but relatively rare
 Often not available.
 Many centers substitute O(+) for men
Would you ever give Rhogam to
a male?
To a non-pregnant female?
 However, some pts have recurrent major
trauma injures requiring transfusions
 Case reports of hemolytic reactions in some pts
 Policy of giving Rhogam to Rh(-) men
receiving O(+) transfusions advocated
Take home points
 That is something that I never
thought of !
Corneal abrasion.
Eye pain for 1-3 days
 It also reflects a societal problem
with repeat trauma offenders
 Little downside, so probably
should give it
 But how much to give?
Dilute proparacaine for management of acute
corneal injuries in the ED
Ball. CJEM. 2010; 12: 389
 CW: no D/C proparicaine to pts = eye toxic
 RCT, 15 adults, Canada
 0.05% proparicaine vs placebo
 All  Opthalmologist F/U
Cycloplegics. Abx ointment.
Pt asks for that “stuff you put in
my eye” for pain relief.
No way!.....…way?
Take home points
 Dogma refuted !
 How does this compare to the
proparicaine used in the ED?
 That is 0.5%
 This is 10 fold weaker: 0.05%
Efficacious and safe
 Better pain relief
 higher satisfaction scores
 No complications or delayed eye healing
 Question: How do I do this?
 How do I dispense to the pt and document
Panacek: Recent lit update
Patient satisfaction scores
becoming increasingly common
Effect of sitting vs standing on perception of
provider time at bedsie
Swayden. Patient Educ Couns. 2012; 86: 166.
 Surgeon on post-operative visits, 120 pts
 RCT to sit vs stand, rest of visit same
What can be done to
improve them?
Actual time
Perceived time
 Stand
1’ 28”
3’ 44”
 Sit
1’ 4”
5’ 14”
 Positive pt feelings: sit= 95%, Stand = 61%
Take home points
 This one is a “no-brainer”
 Unless you can’t find a chair
 Want better pt satisfaction scores?
Pain…cyclic vomiting
and other new plagues
 Sit down instead of standing during
the pt interview or meeting
Two new syndromes I had never
heard ot
Narcotic Bowel Syndrome
Are we seeing the results of long
term use of opioids for chronic abd
Dorn. Clinical Gastro & hepatology. 2011. Dec.
Grover. J Emerg Med. 2011
 Definition: Chronic/recurrent AP associated
with increasing doses of narcotics
 Cause: paradoxical increased pain perception
  functional bowel obstruction from  GI motility
Narcotic bowel syndrome.
Few physicians know of it.
 Sx: crampy recurrent AP, bloating, N/V
 Dx: lab tests all normal
 Pain fails to resolve despite narcotics
 Pain worsens over time with continued opioids
 Withdrawal Sx and worsening if opioids stopped
Panacek: Recent lit update
When should ‘Narcotic Bowel Syndrome’
be suspected/
O’lenic. US Pharm. 2011
 NBS known for decades
 Cellular level biochemistry partially
 Grossly underdiagnosed.
 Narcotic detoxification is only know Tx
 Also: antidepressants, benzos, considered
27M, 3 yr H/O recurrent vomiting and
AP. Many negative work-ups.
Many visits to local ERs:
“I just want answers to my AP”
Is this a case of NBS?
Or something else?
Take home points
 I never heard of this before 2011
 This is iatrogenically caused by
prescribing opioids for chronc AP
 I have seen at least 3 florid cases in
past year
 Patients are not happy to hear this
explanation for their Sx
Cannabinoid hyperemesis: Case series of
98 cases
Simonetta. Mayo Clin Proc. 2012; 87: 114
 Largest collected case series to date
 Recurrent cyclic vomiting/AP without Dx
 H/O MJ use for > 2 years
 Used MJ > weekly
 All were under age 50
 90% reported complete Sx resolution
when stopped MJ use
Hyperemesis and a high water bill
Cannabinoid hyperemesis syndrome (CHS):
Review of proposed Dx and treatment algorithm
Fleig. Z Gastroenerol. 2011; 49: 1479.
Wallace. South Med J. 2011.
 Case report and review
 Recurrent MJ related hyperemesis
 Compulsive hot water bathing that  Sx in
daily MJ users = pathognomonic
 Hot showers were the only Tx that eased
the nausea
 Extensive labs not necessary
 Spent several hours/day in the shower.
 Detox Tx:
 Treatment: cannabis cessation
 Underwent MJ detox and all Sx resolved
 aggressive IVF rehydration
 Mechanism of relief not known
 +/- anti-emetics
 But hot water soaks reported to help N/V in genl
 +/- anxiolytics
Panacek: Recent lit update
Take home points
 Fortunately the HO stopped the pt from going
to the shower
 These may be the face of the new age
 Complications of modern day habits
and over Rx
 Limit opioids to only that which is
clearly necessary
As we near the end…
a reminder
List a few things from this
lecture that will change your
practice this year
Medical technology continues to
grow in breadth and application
Trends come and go
What is the most bizarre application
of current imaging technology that
you haven’t heard of?
What is the latest bizarre
medical trend that you have not
heard of?
Medical tattoos with vital information replacing
bracelets for some
CBS News. 2012 (Feb 27)
The end !