Recent Pubs

We’ve had a bunch of publications in both peer-reviewed and non peer-reviewed sources over the past few weeks! Check them out when you get a chance:

Traficante and Kashani in the Journal of Clinical Toxicology talking about a Massive Calcium Channel Blocker OD

McGovern and D’Amore in Annals of Emergency Medicine talking about Peds EM Education 

D’Amore, McGovern and McNamee in ACEP Now talking about End-tidal for DKA and COPD

Pena, Mota and McGovern in AAEM/RSA Blog going over the elusive Porphyria diagnosis and management 

DeFranco and McGovern in ACOEP’s Fast Track talking about Isolated Bandemia 

 

Just because she cannot pee, does not mean “No UCG”

Let’s face it, we’ve all done it. And, believe me when I tell you all the cool cats are doing it, too.  Of course, I am referring to the use of whole blood to determine a woman’s pregnancy status in the Emergency Department using the urine pregnancy test strip. ucg-bcg-photo-brancato

Did you know that the common ICON 25 Beckman-Coulter hCG tests are actually approved for both urine and serum? Don’t feel bad; I didn’t until I read a recent article. Whole blood, which is comprised of serum (54%), hematocrit (45%) and leukocytes/platelets (1%), was rumored to detect a woman’s pregnancy status.  Now, we have research that confirms our suspicions and demonstrates that whole blood pregnancy testing performs quite excellently.

In a study published in 2012, whole blood pregnancy tests were found to be 96% sensitive, 100% specific with a negative predictive value of 98% and positive predictive value of 100%. Translation: Trust a positive test, it will not be wrong.  Can it miss? Yes, it can; however, there’s a good chance that the urine test will be negative at that point, too (5 of 9 that were missed with whole blood testing of the studied 425 pregnancies were also negative on the urine testing—the other 4 of  9 did not undergo urine testing).

As troops on the front lines of medicine, we are presented often with little time to think or to act. We are adroit at putting puzzle pieces together, often with little information. This is our creed and such is our nature.  It is during these critical cases, that the application of using whole blood pregnancy testing has its greatest application.

Post by: Raphael Brancato, DO (@DrRayFields )

Lisfranc injuries

Quick Review of Lisfranc Injuries

Lisfranc injures are a spectrum which result in a sprain or complete disruption of the tarsometatarsal joints of the midfoot.  They most commonly occur at the base of the 2nd metatarsal with oftentimes subtle or even absent findings on standards x-ray views, especially when they result from low velocity injury.

What is mechanism of Injury?

Usually a result of plantar flexion with external rotation of the ankle (ie. fall from a horse with the foot caught in the foot stirrup, MVC, foot planted in a hole or step off a curb)

Physical Exam on Suspected Lisfranc Fracture

  • Unable to bear weight
  • Hematoma/ecchymosis on medial plantar aspect of foot
  • Dorsal midfoot swelling

Lisfranc foot

For suspected Lisfranc injuries you’ll need three views (AP, lateral and oblique).  On normal foot x-rays you should notice alignment of the 2nd metatarsal on AP view and the medial edge of the base of the 2nd metatarsal should line up with the medial edge of the medial cuneiform.   On the oblique view the 3rd and 4th metatarsal should have the medial edge of the 3rd and 4th metatarsal lining up with the medial edges of the middle and lateral cuneiform.

Lisfranc xray1Lisfranc xry2

Common X-ray findings for Lisfranc Fracture.

  • Widening of > 2mm between the base of the 1st and 2nd or 3rd and 4th metatarsal bases needs surgical intervention
  • “ Fleck Sign” is pathognomonic for a Lisfranc Injury. This is a small bony fragment avulsed from the 2nd metatarsal base or medial cuneiform

lisfranc xray3

What if the X-ray is normal but a Lisfranc injury is still clinically suspected?

  • Add a 30 degree oblique X-ray view
  • Consider ankle nerve block with standing views (Weight bearing stress views).  Similar to the example below with a normal appearing non weight bearing x-ray (left) and then weight-bearing (right) revealing the injury.
  • In patients with clinically suspected Lisfranc injuries and normal or indeterminate radiographic findings, CT or MRI imaging is recommended.
  • Given the superior depiction of soft tissue supporting structures and the ability of soft tissue supporting structures and the ability to detect soft tissue injuries in patients with unstable injuries on MR images, the American College of Radiology Appropriateness Criteria guidelines favors the use of MR imagining
  • Orthopedics surgeons may request high resolution 3D CT images for preoperative planning and for depicting and further characterizing fractures.

 

lisfranc 6       lisfranc6b

 

ED management for patients with Lisfranc Injury

For nondisplaced or suspected injury without radiographic findings, you may place the patient in a posterior back slab. Patient should be non-weight bearing and arrange for orthopedic outpatient follow up two weeks later.  For significantly displaced injury or dislocation (> 2mm widening at the Lisfranc Joint) , Immediate orthopedic referral is needed for urgent outpatient surgical intervention

Post by: Yenis Paez-Perez, DO

Blunt chest trauma

Being in even the most benign car accident imaginable, can be stressful for patients.  Inherently, if they have any chest pain they’re going to be convinced that they’ve sheared their aorta right off its hinges.  While that may be of concern to them, we are pretty certain that their aorta is still intact if they still are alive, but did they sustain a cardiac contusion? How do we figure out if they had one?  And what the heck do we do with them if they did in fact have a cardiac contusion?

1) What are we concerned about in blunt chest trauma?
There are many clinically significant injuries possible in the setting of blunt chest trauma. One that comes to mind is the nebulus diagnosis of “cardiac contusion.”  A lot of the controversy and uncertainty comes from the unclear definition of cardiac contusion which seems to encompass things like myocardial rupture, valvular injury, arrhythmias, cardiac dysfunction, etc. In my mind these types of patients would be more clinically apparent so we’ll focus on the patients who may appear well or relatively so.

2) Do we need to get a troponin in blunt chest trauma?
The answer is yes and no. There is a “guideline” answer and a practical one.
The guideline answer is yes. The 2012 EAST practice guideline for blunt trauma recommends BOTH an EKG and troponin. They state based on their references that a normal EKG in blunt chest trauma has a NPV of 95%. This increases to 100% with a normal troponin. There are several studies that support the use of troponin in this setting and there are instances when EKGs may be normal with a positive troponin. One recent study showed a troponin at 24 hours had 100% NPV for severe cardiac injury.
But the practical answer may be no. There are other studies that are less optimistic regarding the sensitivity and specificity and discourage the use of troponin as a gold standard for diagnosing cardiac contusion from blunt trauma. Another study showed that positive troponins were not a strong predictor of abnormalities on echocardiogram. So getting a troponin may not even matter. However other studies suggested that a positive troponin may be indicative of cardiac contusion or underlying cardiac issue, which brings us to our next question.

3) What do we do with a positive troponin in blunt chest trauma?
One of the arguments against getting a troponin is not knowing what to do with it. If it is negative can they go home? If it’s positive do they need to stay? A 2013 prospective study out of Iran does not recommend troponin as a gold standard in cardiac injury but does encourage intensive cardiac monitoring if an elevated troponin is found. Another study showed that elevated troponin was linked to arrythmias during the patients stay.  So this would suggest admission and tele monitoring for a patient that may have otherwise gone home.

4) Does this change the patients outcome?
Probably not. Three older studies looked at outcomes of patients with cardiac contusions and they really have no long term sequelae and do well.

What’s the bottom line?
Being in a trauma center I would follow the trauma guidelines of getting both an EKG and troponin in the setting of blunt chest trauma. If this is negative with a negative EKG and the patient appears well clinically then likely discharge. However if they have an isolated positive troponin then I would consider admission for 24 hour monitoring for arrythmias with a consideration for inpatient echocardiogram with a reassuring knowledge that they will almost absolutely do well long term.

Post by: Dr. Jordan Jeong, DO (@jeongjom)

Tox Box Journal Club

In this installment of the Tox Box Journal Club we are going over three articles reviewed at the NYC Poison Control Center in Manhattan last week.  Two of the articles discuss utility of lipid emulsion therapy in animal models and a third on the deleterious effects of methotrexate dosing errors in Australia.
Background: LAST = Local Anesthetic Systemic Toxicity is a well described phenomenon which can occur from accidental intravenous administration of anesthetics during peripheral nerve blocks or other procedures. Seizures are often described following accidental intravenous administration, which can then lead to cardiovascular collapse in the setting of severe acidosis and hypoxia. This study was designed to see if there exists a role for lipid emulsion therapy for LAST. Prior animal models did not account for the acidosis / hypoxemia that is known to occur, and this model was able to simulate these settings
Methods: 20 pigs separated into 2 groups of 10. All were anesthetized/paralyzed/intubated. Then infusions of levobupivicaine were administered to each at a dose of 3mg/kg, then five minutes of hypoventilation, then 1mmol/kg of lactic acid infusion (to simulate aforementioned settings). One arm was given Lipid emulsion, the other arm was given Ringer’s acetate. Mean arterial pressure / HR / EKG/QRS/ and plasma concentrations of the anesthetic were all monitored and compared. 
Results: The data show that there was no effect of lipid emulsion compared to that of the ringer’s acetate. QRS took similar amounts of time to narrow in both arms. Pharmacokinetics of Levobupivicaine were the same in both groups. 
Bottom Line: Although there have been case reports describing successful resuscitation of patients who suffer from LAST who were given lipid emulsions during resuscitation, this particular model which simulates acidosis and hypoxemia in pigs, does not support the use of lipid emulsion therapy for local anesthetic toxicity. There seems to be a growing body of lack of support based on this study and others like it. 
 
 
Background: Intravenous lipid emulsion (ILE) is a potential antidote for severe overdoses and its use in cocaine toxicity has been suggested; however, it is not well characterized. Its potential use as an antidote during cocaine toxicity was the focus of this study to see if cocaine-induced cardiac arrest in rats was able to be reversed using this therapy.
Methods: 12 rats were given lethal doses of cocaine IV over 30 seconds, and mechanical chest compressions were initiated once asystole was noted. One arm was given ILE, while the other arm was given a similar bolus rate of 0.9% NS. 
Results: The data show that ILE had no affect in the terminal outcome in cocaine-induced cardiac arrests in this particular rat model, suggesting that this is not an appropriate toxin/antidote pairing. Only 1 of 12 rats received ROSC and was found to be statistically not significant. This rat was in the ILE arm of the study.
Bottom Line:  This article demonstrates some potential design flaws including small sample size,  and withholding ACLS medications post cardiac arrest which potentially would have aided in resuscitation. 
This was a retrospective review article which sheds light upon the fatal errors which can occur as a result of accidental, improper dosing of methotrexate (MTX).  After looking at the Australian database for reported poisonings, errors occurred for a number of reasons and the ones most commonly identified were: 
  •  mistaking medication for another medication
  •  care-giver/nursing home error
  •  MTX was newly prescribed medication
  •  pharmacy dosing packet error
  •  misunderstood directions
  •  patient believing it would improve efficacy
  •  prescribing error by physician
  •  dispensing error
  •  labeling error 
As a result there were 22 deaths noted to be linked to MTX administration errors
Bottom Line:  These medication errors are not uncommon, and because MTX is a high risk medication which can become fatal if taken incorrectly, further care is warranted in dealing safely with this medicine. A multi-faceted approach should be considered and suggestions are still ongoing. Some recent suggestions have been to change packet size, to increase education/awareness, mandatory weekly dosing labeling on packaging, including software alerts for prescribers and dispensers
Post by: Dr. Ray Brancato (@drrayfields)

Endophthal….what?

It’s difficult to miss a raging STEMI or a CVA with unilateral flaccid paralysis, but there are other, less-sexy diagnoses that we have the opportunity to make in the Emergency Department that can be as important and impactful to the patient’s health.  Endophthalmitis is a difficult word to spell and equally as difficult to diagnose if you’re not looking for it.  Check out Dave Traficante’s recent post on EM Resident on Endophthalmitis.

Fixed dose PCC?

In the past, vitamin K and FFP were the mainstays of reversing warfarin, but now we have fancy new drugs like four-factor prothrombin complex concentrate (4F-PCCs).  4F-PCCs can rapidly reverse the INR of warfarin induced coagulopathy with less volume and quicker than FFP.  Many of the dosing regimens base the dose on the patient’s presenting INR and body weight, with ranges from 25-50 IU/kg.  A few problems arise with this approach, first the INR is not immediately available.  Second, 4F-PCCs are not cheap; costing up to $7,000 per patient in some cases.  Is there a fixed-dose regimen that we can give to patients on vitamin K antagonists without having to wait for the INR?

Some studies have looked at using 500 IU and 1000 IU fixed dose regimens for reversing the INR.  The 500 IU only corrected the INR in 43% of the patients, whereas the 1000 IU fixed dose study showed better clinical outcomes in 83.5% of the patients, but there is concern that the obesity epidemic in the United States will dilute the IU/kg concentration of the 4F-PCC and not be as efficacious.  Klein et al looked at using a fixed dose of 1500 IU of 4F-PCC for reversal of warfarin in 2015.  It was a relatively small sample of 38 patients on warfarin with the vast majority of them presenting with an intracranial hemorrhage.  Each patient had their INR drawn and then 1500 IU given before the result of the INR returned.  92.3% of the patients had their INR lowered to less than 2.0 after the 1500 IU of 4F-PCC and they reported no thrombotic events within the subsequent 7 days.  The presenting INR median was 3.3 (2.5-4.0) which was reduced to 1.4 (1.2-1.6) after administration of the 4F-PCC.  Additionally, this saved $40,273 dollars when compared to the typical INR and weight based dosing regimen for their patient sample.

We’ll have to figure out whether this fixed dose regimen of 1500 IU is the way to go, or should we base the dose solely on the patient’s weight and not worry about waiting on the INR.  Does waiting the extra 20 minutes for the INR lead to improved clinical outcomes?  And if we are going to start using a standard dose, is there a role for pre-hospital administration of the 4F-PCCs?

Post by: Terrance McGovern DO, MPH (@drtmcg13)

Abdominal CPR?

There was a case report published in the Western Journal of Emergency Medicine last year about interposed abdominal compression CPR (IAC-CPR).  Personally, I’ve never heard anything of the sort and had to take a deeper look into it.  Essentially, you need two people to do compressions, one for the chest and one for the abdomen.  The abdominal compressor performs CPR with their hands about 5cm above the umbilicus and compressing about as deep as you would need to palpate the abdominal aorta pulse.  Both compress at the same rate and alternate their compressions; chest-abdomen-chest-abdomen and so on.  Theoretically, the abdominal compressor is acting as an external intra-aortic balloon pump.  By compressing the aorta during diastole, there is retrograde blood flow back into the coronaries.  Additionally, this abdominal compression increases venous return and promotes forward flow of the intrathoracic blood pool.  There have been no intra-abdominal injuries noted in survivors besides one pediatric traumatic pancreatitis reported in 1984.  The most recent review of IAC-CPR in Resuscitation showed significant improvements in the probability of achieving ROSC in the pre-hospital and in-hospital cardiac arrests when compared to standard CPR.  The question for me is why are we not doing this more? Is there harm in trying it if the person is already in cardiac arrest?

Post by: Terrance McGovern DO, MPH (@drtmcg13)

When kids eat coins

Kids eat up your money in more ways than one.  Some may eat it up in the form of $50,000 a year in college tuition and some eat it up as a meal.  For coins that get stuck in the esophagus the American Society for Gastrointestinal Endoscopy recommends watching asymptomatic patients for a period of 24 hours prior to any intervention.  Once the coins passes into the stomach most will traverse the GI tract without any complication.  There are multiple different methods of retrieving coins that are lodged in the esophagus: endoscopy, foley catheter technique, glucagon and bougienage is a method of pushing the coin into the stomach.  Classically, you use a Hurst dilator (or build your own) and advance it down the child’s esophagus to push the coin past the lower esophageal sphincter (step-by-step instructions).  Bougienage, when used on appropriate patients, is a safe modality for treating esophageal coins with only minor complications reported.  Some have reported success rates as high as 95%; however, you have to stick to the following inclusion criteria:

  1. Witnessed ingestion
  2. Foreign body is a coin
  3. Coin is seen in the esophagus on x-ray
  4. Single coin is present
  5. Ingestion < 24 hrs
  6. No previous esophagus procedure or pathology
  7. No respiratory symptoms
  8. Performed by trained personnel

If you successfully get the coin to pass into the stomach then the patient can be discharged home.  If the piggy bank doesn’t give up the coin in the next 2 weeks, then the patient will need a repeat xray to see where it is.  Check out this ACEP Now article for a more detailed discussion of bougienage.

Post by: Terrance McGovern DO, MPH (@drtmcg13)

 

Top 10 Infectious Disease Updates

I recently gave an “ID Updates” lecture at AAEM’s Scientific Assembly in Las Vegas, February 2016. Here are the top 10 pearls from my lecture. Some may be review, some more cutting edge. Enjoy!

  1. Use ultrasound to help guide diagnosis and management of suspected skin and soft tissue abscesses

The literature is mixed on this one but it makes sense to use ultrasound. Ultrasound seems to increase your diagnostic sensitivity and may affect management, especially in those “gray zone cases”. If you are feeling ambitious, use ultrasound after I & D to assess the success of your I & D. Plus, it’s pretty easy to do!

Alsaawi, A et al. European Journal of EM. 2016.

 

  1. Although guidelines still recommend solely I & D as the treatment of choice for simple skin and soft tissue abscesses, maybe antibiotics are not so bad!

A recent trial from Talan et al. from NEJM supports the use of antibiotics in skin and soft tissue abscesses. Antibiotics increased clinical cure and decreased complications. The knock on this trial is the included patients would have received antibiotics anyway based on disease severity; nonetheless, antibiotics benefitted patients with little harm.

Talan D et al. New England Journal of Medicine. 2016.

 

  1. First line treatment for suspected sexually transmitted infections (cervicitis, urethritis) is dual therapy Ceftriaxone 250 mg IM and Azithromycin 1 gram po.

Cefixime used to be a first line alternative (instead of Ceftriaxone), however, it is no longer with increasing resistance patterns. Bottom line—give dual therapy! Consider challenging patients who have a PCN allergy with Ceftriaxone. If you’re not going to give dual therapy with Ceftriaxone/Azithromycin, the reason better be good!

www.cdc.gov

 

  1. Newest GI recommendations state that antibiotics probably do not reduce symptom duration for uncomplicated CT proven diverticulitis.

Yes, I said it—no antibiotics for acute uncomplicated diverticulitis! Certainly, we would like to see more literature in this area, but the literature we do have show antibiotics do not improve symptoms. Antibiotics may however decrease complications, as per the guidelines. I’d like to see more here, but check out the references and see for yourself.

Strate L et al. Gastroenterology. 2015.

 

  1. Non-operative management of appendicitis is an option.

We’re not here yet in the U.S. but they are in Europe. In the newest Lancet study, 73% of patients who received non-operative management did not require an appendectomy out to one year. Those that failed non-operative management did not have complications of sepsis, abscess, or rupture compared to the operative group. The theory for non-operative management is not all appendicitis is an obstructive process that requires removal; some may respond to medical therapy.

Salminen P et al. JAMA. 2015.

 

  1. Timing of antibiotics does not reduce mortality from severe sepsis/septic shock.

CMS dictates we administer antibiotics within 3 hours of diagnosing severe sepsis/septic shock in the ED. It’s a core measure we need to meet. But it does not reduce mortality per a recent systematic review from Critical Care. Timing of antibiotics may be important, but antibiotic selection is probably more important.

Sterling S et al. Critical Care Medicine. 2015.

 

  1. Irrigation pressures do not matter in the management of open fractures.

In the OR, whether patients with open fractures get very low pressure, low pressure, or high pressure irrigation, re-op rates are the same!

The Flow Investigators. New England Journal of Medicine. 2015.

 

  1. Consider use of corticosteroids in inpatients with pneumonia.

Adjunctive prednisone in pneumonia reduced inpatient stay.

Angela Blum C et al. Lancet. 2015.

 

  1. It is thought that Strep sp. are the predominant organisms in cellulitis. But maybe not!

If Bactrim works as well as Clinda, Strep may not be the king organism in undifferentiated skin and soft tissue infections. Check out the reference.

Miller L et al. New England Journal of Medicine. 2015.

 

  1. Respect lactate!

We know lactate is not specific. But in the setting of infection or suspected sepsis, respect it if it is positive, even if in the intermediate range. Intermediate level lactates had a 30 day mortality of 15%.

Singh M et al. Annals of EM. In Press.

Post by: Nilesh Patel, DO (@nnpatel1291