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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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.

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.

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

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

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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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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.

It’s one of the most common fractures we see in the ED, but how important is it to get a perfect reduction? Is it even worthwhile to try? There are arguments on both sides of that question.

Pro

-Anecdotally, pain is improved when a severely displaced fracture is reduced and immobilized.

-The ED has sedation capabilities that the orthopedist’s office does not. If we can get good anatomic alignment in the ED and save a trip to the OR, we’ve benefitted the patient

-You are treating the patient for their presenting complaint

Con

-A significant portion of reduced fractures will fall out of reduction

-They are a huge time and resource sink. Time to reach NPO status keeps a bed occupied. The sedation and splinting involve multiple staff members. A nurse is taken away from other ED patients for as long as the patient needs close monitoring

-Many of these patients may not actually benefit from reduction.

Do you like to reduce Colles fractures? If so, have at it. They’re one of my favorite procedures and I rarely pass up the chance. But there is no fault in splinting and referring to the orthopedist as long as the skin and neurovascular exam are intact. You just need to explain to the patient/family why you’re not fixing a deformed wrist.

Written Summary:  Justin Arambasick MD  Akron General  Medical Center

Consult with Hans Moller, MD

Does a mild to moderate (< 35˚) nonarticular fracture of the distal radius have to be reduced?
Not necessarily. Many countries in Europe do no perform surgery or reduction on
these, and a variety of low powered studies have not shown functional benefit
in doing so.

Is there a benefit to doing an ED reduction?
Yes, patients whom have had a reduction in the ED and show up in the orthopedic
follow up clinic have in general better pain control and less skin changes.

When should a patient follow up with orthopedics after an ED reduction?
7-10days

Does intraarticular involvement necessitate a trip to the OR?
Not necessarily.  These fractures are at higher risk for subsequent arthritis, which can be mitigated by surgery (but not completely prevented). The problem with these is that the pieces of the fracture tend to drift apart, increasing the chance of an unfavorable outcome.

What is radial shortening?This refers to the length of the radius comparing the carpal articular surface of the ulna and the lunate fossa of the radius. A line drawn across the end of the ulna should be at the same level as the radial lunate fossa. If the lunate fossa is behind (proximal to) this line, the radius is shortened.

 Radial length

Radial Shortening (yellow arrow)

What is the purpose of finger traps?
To elongate the shortened radius. Hans prefers placing the thumb and
index finger in the trap and separating them by a 3 inch roll of Webril, thus
elongating the radius and providing ulnar deviation.  Place splint on while
still in trap.

What are the hallmarks of an adequate fracture reduction?
<2mm articular step off
<20 degrees of volar angulation
<3mm of radial shortening
With these parameters, the functional outcome should be the same as someone who has had surgery.  Surgery has quicker return to full function than casting.

Here is the audio

Papers Discussed
Injury. 2010 Jun;41(6):592-8. Epub 2009 Dec 2.
The efficacy of closed reduction in displaced distal radius fractures.
Neidenbach P, Audigé L, Wilhelmi-Mock M, Hanson B, De Boer P.

J Bone Joint Surg Am. 2010 Aug 4;92(9):1851-7.
Distal radial fractures in the elderly: operative compared with nonoperative treatment.
Egol KA, Walsh M, Romo-Cardoso S, Dorsky S, Paksima N.

HTN should be straightforward, so why is it confusing? Part of the problem is terminology. Shayne and Pitts got it right in 2003 when they made sense of classifying different hypertensive scenarios. What in the world do accelerated, malignant, urgent and malignant HTN mean? I have no idea either. Here’s the Shane and Pitts BP breakdown….

Severely elevated blood pressure can be thought of in three ways:

Hypertensive emergency: end organ damage because of severely increased blood pressure. In this scenario, BP should be lowered in the next 1 to 2 hours.

Hypertensive urgency: severely elevated blood pressure in patients at high risk for acute end organ damage but without evidence of new injury. This includes a history of prior end organ disease like CHF, unstable angina, renal failure, CVA, etc. Do these patients need to be admitted or have immediate BP reduction in the ED? Your decision will be physician comfort level based rather than evidence based, because there’s no evidence so say what’s the right thing to do. However, you should have increased vigilance. If the patient is discharged, set up a plan for BP reduction and follow-up in a day or two.

Everyone else is in the third group: Uncontrolled Severe HTN.  The most important management piece here is good follow up. You may end up starting these patients on antihypertensives in the ED, or maybe they’ll be referred for a BP recheck in a week because this was a first reading of high BP or they had an acute painful condition that confounded to the picture.

In the old system, where everyone with really high blood pressure but without end organ dysfunction was classified as an urgency, it was hard to organize treatment and disposition. With this grouping: emergency, urgency and uncontrolled severe HTN, I find it easier to organize my treamtent and disposition.

And now for some shownote goodness from my man, Justin Arambassick, MD…

What lab tests should you think about before starting or changing BP meds?
 Urine
o   PROTEIN IN URINE = KIDNEY DAMAGE
o   This may be due to the hypertension itself or another disease process such
as diabetes.
o   Either way, the drugs of choice in the setting of proteinuria are ACE
inhibitors (e.g. lisinopril) or ARB angiotensin receptor blockers (e.g.
losartan).
In general, no benefit to giving a combination of an ACE and an ARB.
Blood
Creatinine, if elevated:
o   ACE or ARB first line treatment, though start at low dose and monitor Cr
o   These medications may cause kidney injury by reducing GFR (glomerular
filtration rate)
o   Contraindicated in bilateral renal stenosis
o   Monitor that the patient is not dehydrated or on other medications that may
stress the kidney
o   If these meds are started, the patient must have good follow-up for
creatinine and potassium monitoring.

Sodium

o   If low, avoid thiazide diuretics

o   Furosemide and loop diuretics do not affect as much, though you probably do not want to start loop diuretics either

ALLHAT study conclusions

o   No significant difference in all-cause mortality, fatal heart disease, or
non-fatal myocardial infarction when chlorthalidone was compared with lisinopril
or amlodipine

o   Decrease rate of heart failure after 6 years in chlorthalidone group compared with amlodipine

o   Study conclusion: thiazide-type diuretics are preferred first-step in antihypertensive therapy.

ACCOMPLISH trial

o    ACE and a CCB are a more effective combination than ACE plus a diuretic.
o   Among the patients taking the ACEI/CCB combination, 81.7% had their BP
controlled to < 140/90 mm Hg compared with 78.5% of the ACEI/HCTZ group.o   Approximately 50% of patients still on only the designated study medication(no add-ons) at 30 months.

JNC 7

General rules:

First line treatment is a thiazide diuretic (chlorthalidone was the medication originally studied, not hydrochlorothiazide.) Chlorthalidone is more potent, though has more side effects than hydrocholorthiazide.

If a patient has severe asthma don’t start a beta blocker

If a patient has coronary artery disease,  ACE and a
beta blocker
If a young healthy patient: ACE-I
If African American: thiazide diuretic or calcium channel blocker

Algorithmic approach to starting antihypertensive meds

Links mentioned in the show

Cliff Reid’s Resus M.E, Zdogg’s CallDay video

Here is the audio

Interview with emergency medicine luminary David Newman of…

SMART EM

The NNT website

Hippocrates Shadow: Secrets from the House of Medicine

Here is the audio