ERcast has changed its address and has a brand spankin new website. Come check it out!

Out with the old…and in with the new

After wandering in the wilderness of pixelated paranoia – I have seen the light and decided to collate the accumulated eclectic into one central, pertinent repository of goodness…over at http://blog.ercast.org. The old link http://ercast.org still works and will direct you to the new site, so if that’s the one you have saved, no worries.

If you were a subscriber to the old site, you will need to re-subscribe on the new one to get the latest ERcast updates. Many thanks to my friend Mike Cadogan (@sandnsurf) of LITFL who remade the entire website while I cheered from the sideline and marveled at his generosity of time and expertise.

Thanks for listening to the show!

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Mark Crislip on Vaccines and Why You Should Get a Flu Shot

As interview with podcast and blogging grandmaster Mark Crislip, MD on vaccinology and influenza.

Direct Download

Mark’s website

CDC Flu Site

CDC info for clinicians on antiviral medications and influenza testing

Check out ZdoggMD’s video ‘Immunize’. Honorable mention winner of the 2011 Disposable Film Festival.

And last, but certainly not least, Mark Crislip’s

A Budget of Dumb Asses

I wonder if you are one of those Dumb Asses who do not get the flu shot each year? Yes. Dumb Ass. Big D, big A. You may be allergic to the vaccine, you may have had Guillain Barre, in which case I will cut you some slack. But if you don’t have those conditions and you work in health care and you don’t get a vaccine for one of the following reasons, you are a dumb ass.

1. The vaccine gives me the flu. Dumb Ass.

It is a killed vaccine. It cannot give you the influenza. It is impossible to get flu from the influenza vaccine.

2. I never get the flu, so I don’t need the vaccine. Irresponsible Dumb Ass.

I have never had a head on collision, but I wear my seat belt. And you probably don’t use a condom either. So far you have been lucky, and you are a potential winner of a Darwin Award, although since you don’t use a condom, you are unfortunately still in the gene pool.

3. Only old people get the flu. Selfish Dumb Ass.

Influenza can infect anyone, and one of the groups who are more likely to die of influenza are the very young. Often those most at risk for dying from influenza are those least able, due to age or underlying diseases, to respond to the vaccine. You can help prevent your old, sickly Grandmother or your newborn daughter from getting influenza by getting the vaccine, so you do not get flu and pass it one to her. Flu, by the way, is highly contagious, with 20 to 50% of contacts with an index case getting the flu.  However, Granny may be sitting on a fortune that will come to you, and killing her off with the flu is a great way to get her out of the way and never be caught.  That would make a good episode of CSI.

4. I can prevent influenza or treat it by taking Echinacea, vitamin C or airborne. Gullible Dumb Ass Cubed Then Squared.

None of these concoctions has any efficacy what so ever against influenza. They neither prevent nor treat influenza. And you can’t boost you immune system either. Immunity is not a Jamba Juice. Anyone who says that the immune system can be boosted is also a dumb ass.

5. Flu isn’t all that bad a disease. Underestimating Dumb Ass.

Part of the problem with the term flu is that it is used both as a generic term for damn near any viral illness with a fever and is also used for a severe viral pneumonia. Medical people are just as inaccurate about using the term as the general public. The influenza virus directly and indirectly kills 30,000 people and leads to hospitalization of 200,000 in the US each year. Influenza is a nasty lung illness. And what is stomach ‘flu’? No such thing, dumb ass.

6. I am not at risk for flu. Denying Dumb Ass.

If you breathe, you are risk for influenza. Here are the groups of people who should not get the flu vaccine (outside of people with severe adverse reactions to the vaccine): Former President Clinton, who evidently doesn’t inhale. And people who want to be safe from zombies. If you don’t get the vaccine you do not have to worry about the zombie apocalypse, because zombies eat brains.

7. The vaccine is worse than the disease. Dumb Ass AND a Wimp.

What a combination. Your mother must be proud. Unless you think a sore deltoid for a day is too high a price to pay to prevent two weeks of high fevers, severe muscles aches, and intractable cough.

8. I had the vaccine last year, so I do not need it this year. Uneducated Dumb Ass.

Each year new strains of influenza circulate across the world. Last years vaccine at best provides only partial protection. Every year you need a new shot. And we have a new strain this season, H1N1, so you cannot be a parasite on the immunity of others.

9. The vaccine costs too much. Cheap Dumb Ass.

The vaccine costs less than a funeral, less than Tamiflu, less than a week in the hospital.

10.  I received the vaccine and I got the flu anyway.  Inexact Dumb Ass.

The vaccine is not perfect and you may have indeed had the flu.  More likely you called one of the many colds people get each year the flu.  Remember there are hundreds of potential causes of a respiratory infection circulating, the vaccine only covers influenza, the virus most likely to kill you and yours.

11. I don’t believe in the flu vaccine.  Superstitious, Premodern, Magical Thinking Dumb Ass.

What is there to believe in?  Belief is what you do when there is no data. Probably don’t believe in gravity or germ theory either. Everyone, I suppose, has to believe in something, and I believe I will have a beer.

12. The government puts tracking nanobots in the vaccine as well as RFID chips as part of the mark of the beast, and the vaccine doesn’t work since it is part of a big government sponsored conspiracy to line the pockets of big pharma and inject the American sheeple with exotic new infections in an attempt to control population growth and help usher in a New World Order. Well, that excuse is at least reasonable. Paranoid Dumb Ass.


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RLQ pain in pregnancy. Bonus track: the return of Zdoggmd

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The list of potential badness in the pregnant patient with right lower quadrant pain is long and distinguished, but it often comes down to a simple question, “Does this patient have appendicitis?” The subtext of this question is, “Is this patient going to need a CT scan?” Nobody likes ordering am abdominal CT on a pregnant patient because, no matter how low the statistical risk of damage to the fetus, there is still potential harm from ionizing radiation. As you will see below, the risk of immediate  maternal and fetal harm is far greater than the long term risk of ionizing radiation exposure.

Interview with Ingrid Lim MD at ACEP 2011

Risk of mortality with appendicitis in pregnancy:

In a pregnant patient with unperforated appendicitis, fetal loss is 3-5%. With perforation, fetal loss skyrockets: -30% in trimesters 1 and 2 -70% in trimester 3

Maternal mortality is 1% without  perforation and 4% with perforation

Diagnosis:

Step 1: Ultrasound- more sensitive in the 1st vs. 3rd trimester. Even though it may be inconclusive as far as appendicitis, ultrasound can give valuable information about the fetus, uterus, ovaries, kidneys and gallbladder. If ultrasound doesn’t give the answer….

Step 2: MRI without contrast DO NOT USE GADOLINIUM:CONTRAINDICATED IN PREGNANCY If no MRI available…

Step 3: CT with or without contrast depends on your local radiologist. Contrast (IV or PO) is considered safe in pregnancy. Research has shown that contrast does not harm fetal thyroid

RADIATION PRIMER for CT Appy protocol 

Fetal background radiation exposure during 9 months of pregnancy 0.1 rad (1mGy) Teratogenesis threshold: 5 rad (50mGy)

Estimated fetal radiation exposure from CT Appy protocol:

Trimester 1: 2.4 rad (24mGy)

Trimesters 2 and 3: 3 rad (30mGy)

Teratogenesis – fetal death. malformation or developmental delay from in utero radiation exposure. The threshold for a <1% teratogenesis risk is 5 rad (50mGy). The highest risk period is 3-15 weeks. The amount of radiation absorbed from a CT appy protocol is less than the 5 rad teratogenic threshold.   Even with exposure to 10 rads,  there is a 99% chance of no fetal teratogenic effects.

Carcinogenesis-    Most worrisome for childhood cancers such as leukemia. The baseline risk of dying from childhood cancer is  1 in 2000. A 5 rad exposure is believed to increase that risk to 2 in 2000. While that is a doubling of the relative risk, it is still small compared the rate of fetal loss from a ruptured appendix.

Bonus section: Ectopic Pregnancy and HCG levels

Traditional teaching holds that if the HCG does not double in the first 48 hours, consider ectopic. But many patients do not follow this curve. With  the development of more sensitive assays, a minimum rise of 53% over 48 hrs is acceptable. 3% of ectopic pregnancies can have a negative serum HCG

Two theories: 1.     Have to have a viable trophoblast to produce HCG, no trophoblast…no HCG    2.  Ectopic died then ruptured

Bottom line, if patient looks sick and there is a lot of free fluid in the pelvis –go to surgery

Written Summary:  Justin Arambasick MD  Akron General  Medical Center and Rob Orman MD

A good article on MRI uses in pregnancy

The Disposable Film Festival

Research and Reviews in Emergency Medicine and Critical Care is an amazing project thatbrings together physicians from across the globe to find the hottest medical articles on the planet. This is an international collaboration with  contributers  from Ireland, UK, South Africa, Australia and the United States. If you want to see what’s making waves in the medical world and stay up to date on current trends in emergency medicine and critical care,  click here to go to R and R post 1.


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Hyphema

Hyphema

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Written Summary:  Justin Arambasick MD  Akron General  Medical Center
                        
Hyphema:  blood in the anterior chamber of the eye. It may appear as a reddish tinge, or it may appear as a small pool of blood at the bottom of the iris or in the cornea.
Grade 1 – less than 1/3rd of anterior chamber
Grade 2 – 1/3 to 1/2 of anterior chamber
Grade 3 -greater than 1/2 but less than grade 4 (see below)
Grade 4 – Anterior chamber completely filled, also known as 8 ball hyphema
Causes:
Blunt trauma-most common cause, generally the vessels that join to iris to the eye
Spontaneous
Lymphoma
Leukemia
Child abuse
Post surgical
Does it matter how much blood accumulates?
Yes a large bleed is worse than a micro bleed but both are really sentinel events for the potentially worse re-bleed. It is the re-bleed that carries a higher risk of blindness.
How do you prevent the re-bleed?
Bed rest or light activity
To prevent a re-bleed into the anterior chamber which may cause obstruction of vision, or a rise in intraocular pressure. No reading – movement of the eye can precipitate loosening or loss of clot.
Elevation of the head of the bed
Approximately 30 – 45 degrees (so that the hyphema can settle out inferiorly and avoid obstruction of vision, as well as to facilitate resolution) laying flat will not cause any permanent deficit though will cause difficulty seeing or blurry vision.
Wearing of an eye shield
This prevents accidental rubbing of the eyes, which can precipitate a re-bleed.  DO NOT APPLY PRESSURE TO EYE. Use a metallic Fox Shield or paper cup
Avoidance of NSAIDS
 Aspirin or ibuprofen (which thin the blood and increase the risk of a re-bleed) – instead, acetaminophen can be used for pain control.
Sickle Cell Screen
If African American or Mediterranean check for sickle cell disease, patients are at increased risk even if just sickle cell trait. MUST KNOW THIS IS GOING TO GIVE DIAMOX AS IT CAN CAUSE SICKLING.
Medical Treatment
 Aminocaproic acid -  to reduce further bleeding (decreases the likelihood of a re-bleed)
Aminocaproic acid (also known as Amicar,) is a derivative and analogue of the amino acid lysine, which makes it an effective inhibitor for proteolytic enzymes like plasmin, the enzyme responsible for fibrinolysis. For this reason it is effective in treatment of certain bleeding disorders .
Cycloplegic eye drops – to dilate and rest the pupil
The best is atropine because it completely paralyzes the movement of the iris, where other cyclopleigic drops allow for some movement.
Check Intraocular Pressure 2 reasons
1.      Blood can clog the trabecular meshwork and cause the IOP to become dangerously high
2.      Elevated pressure can cause blood cells to be forced into the eye causing staining of the cornea
Elevated Intraocular Pressure Treatment
1.      Timolol – B-blocker that is a aqueous suppressant, quick acting and few side effects
2.      Topical carbonic anhydrase inhibitor -Inhibition of carbonic anhydrase in the ciliary processes of the eye decreases aqueous humor secretion and thus lowers the intraocular pressure in the anterior chamber
a.       Brinzolamide (trade name Azopt)
b.      Acetazolamide  (trade name Diamox) – can be given IV in extreme cases
c.       Dorzolamide (trade name Trusopt)
3.      Alpha 2 agonists- acts via decreasing synthesis of aqueous humor, and increasing the amount that drains from the eye through uveoscleral outflow
a.       Brimonidine (trade names Alphagan and Alphagan-P)
b.      Apraclonidine (trade name Iopidine)
4.      VERY RARELY- Paracentesis may be preformed

From the land down under, a must have for every ED: Link to The Emergency Eye Manual

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Do we still need spinal tap following a negative CT in worst headache of life?

It’s deeply rooted medical dogma that spinal tap needs to follow a negative CT when evaluating patients for subarachnoid hemorrhage. New literature has come out to challenge that idea. We talk with Scott Weingart of emcrit.org and Ryan Radecki of Emergency Medicine Literature of Note about a 2011 BMJ paper that looks at the sensitivity of computed tomography when performed within 6 hours of headache onset.

Keeping with the neurology theme, what’s the story with awake blunt trauma patients with a negative cervical spine CT who still have neck pain. Do they need an MRI?

Also…

Broome Docs in Western Australia

Justin Arambasick gets published in EP monthly

Zdoggmd has been busy

CLICK HERE FOR DIRECT DOWNLOAD

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Suicide risk assessment in the emergency department: a how to guide

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Download from iTunes

Click on “Suicide Risk Assessment” in the banner above to get the quick reference card, mnemonic explanation and sample documentation.

I look forward to your comments and feedback.


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The propofol assassins. US vs CT for appy. Defensive documentation. Can you really be allergic to iodine?

ERCAST Rant-Off 2011

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It’s open mike time for whatever get’s your goat (in medicine, that is). Featured rants…

Cliff Reid of resus.me: The Propofol Assassins

Dave Peaslee: “Do you know what medicines you’re on, sir?”

Andy Neill of emergencymedicineireland: Are we thinking about PE the right way?

Mike and Matt from the emergency ultrasound podcast: US vs CT for appendicitis

Resident Jim: How I feel about attendings who do a full H&P before I get in the room

Dan Gromis: Can you really be allergic to iodine? I think not!

Gerry O’Malley: Why do we teach residents defensive documentation?

Steve Ayers: When can you really say someone has HTN?

Mike Jasumback: Wants an emergency medicine forum. Email him at EMforum@live.com

Haven’t subscribed to ercast in itunes yet? Here’s how.

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