PRACTICE CHANGERS?

• The following articles are potential practice changers that for some reason never got the publicity they may have deserved.  Read them and make your own decision.

• I have summarized my own take home points then linked to the article

ANALGESIA:

• Zofran: no prophylactic anti-emetics:
  • Prophylactic Zofran is usually not needed with opiates as less than 20% develop nausea and Zofran doesn’t necessarily prevent it.
  • Zofran should be considered if nausea if it is already present or subsequently develops.
  • Reference
• Toradol: use less Toradol:
  • Ibuprofen is usually just as effective and has a better safety profile.
• Toradol: use dose of ~15mg:
  • There is a ceiling effect for analgesia at 10-15mg.
  • Reference

CARDIOLOGY:

• SVT: modified Valsalva for SVT:
  • The modified Valsalva is about 40% effective for SVT.
  • Reference
• SVT: diltiazem better than adenosine for SVT:
  • Diltiazem is easier, cheaper, more effective and better tolerated than adenosine for SVT.
  • Significant drop in BP is very rare.
  • Diltiazem should usually be first line for SVT unless the patient is hypotensive or has an allergy.
  • Reference
• V-fib: meds don’t work for V-fib:
  • Amioarone = lidocaine = placebo for shock resistant V-fib

ENT:

• Vertigo: steroids beneficial for vestibular neuronitis:
  • Steroids led to more rapid recovery in viral causes of vertigo.
  • Reference

NEUROLOGY

• Stroke: PRISM study – aspirin safer than tPA for minor strokes
  • Included: NIH stroke score 0-5 and stroke “non-disabling”
  • Aspirin did just as well with fewer IC bleeds (0 v 3.2% symptomatic IC bleed)
  • Reference
• TIA: Workup & Disposition
  • It’s complicated, but best risk scores involve imaging in addition to ABCD’s
  • ABCD3-I rule: 3rd D is Dual TIA and I is for Imaging (duplex + MRI)
  • Reference
• TIA: aspirin PLUS Plavix:
  • Aspirin PLUS Plavix should be considered for secondary prevention for the first 1-3 weeks after a significant TIA (ABCD2 score of 4 or higher) or minor stroke (NIHSS of 3 or less).
  • With major strokes aspirin alone is recommended due to higher risk of bleeding.
  • Reference.
  • Summary Chart

PROCEDURES:

• Lumbar Puncture: CT before LP indications: IDSA guidelines associated w/ delays in treatment and thereby worse outcomes than Swedish guidelines. Reference
  • Swedish Guidelines: symptom duration >4 days, pronator drift or signs of herniation (GCS<6 w/ non-reactive pupil, opisthotonus, abnormal breathing, or HTN w/ slow HR).
  • IDSA Guidelines: decreased immunity, focal CNS history, seizure in the past 1 week, AMS, focal neuro exam or papilledema (wear a mask if checking for this).
• Intubation: BUHE for intubation:
  • Back Up Head Elevated position decreased complications by 13% and offered a better view of the vocal cords

PULMONOLOGY:

• Pneumonia: steroids beneficial for admitted pneumonia:
  • Steroids may decrease mortality in patients admitted for pneumonia.
  • Reference 1
  • Reference 2
  • For severe community-acquired pneumonia (CAP) corticosteroids reduce morbidity and mortality with a NNT = 18 to prevent one death. For non-severe CAP admissions, corticosteroids reduce morbidity, but not mortality, with a reduction in time to clinical cure, length of hospital stay, total ICU days, rate of respiratory failure or shock and other complications.  Most adult studies used a dose equivalent of ~50 mg prednisone/day for 7 days.
    References:
    (1) Seagraves T, et al. Ann Emerg Med. 2019 Jul;74(1):e1-e3.
    (2) Pliakos EE, et al. Chest. 2019 Apr;155(4):787-794.
    (3) Stern A, et al. Cochrane Database Syst Rev. 2017 Dec 13;12:CD007720.

RENAL

• Hyperkalemia: consider newer agents instead of Kayexalate
  • Kayexalate is unproven and has rare incidence of colonic necrosis
  • Newer options: patiromer (Veltassa), sodium zirconium cyclosilicate (ZS-9, Lokelma)
  • Reference

TRAUMA

• Head Injury + Blood thinners: Obs or repeat head CT rarely indicated
  • Average risk of delayed IC bleed in patients with mild head injury on blood thinners is ~0.6% and risk of needing intervention is ~0.13%.
  • Observation and/or repeat head CT likely not indicated unless additional risks are present such as INR >3, bad mechanism, poor social situation, etc.
  • Reference

UROLOGY

• Kidney Stones: predictors of kidney stone being infected:
  • USEFUL: >20 WBC/hpf, >20 bacteria/hpf, nitrite+ or pH >7.5 on UA.  Staghorn calculus
  • DEPENDS: CRP >1.5, age >54, female.
  • NOT USEFUL: short duration of pain, voiding symptoms, CBC leukocytosis.
  • Reference
• Kidney Stones: risk of + urine culture based on UA:
  • In study below, ~15% of patients with stones had pyuria (>10 WBC/hpf)
  • >50 WBC: ~60% had a positive culture
  • 10-20 WBC: ~10% had a positive culture
  • <10 WBC: ~3% had a positive culture
  • Reference
  • Estimate: risk of positive culture is about the number of WBC/hpf on UA
  • Nitrites (+): about 95% specific for UTI (~35% sensitive)
  • Bacteria: about 90% specific for UTI unless rare or few (~50% sensitive)
• Kidney Stones: no need to prescribe Flomax:
  • A well done RCT of 512 patients.  Stones >9mm were excluded.
  • Stone passage by 28 days was 49.6% vs. 47.3% in the placebo group.
  • Reference
  • Flomax can cause hypotension
• Kidney Stones: sex may help passage of kidney stones:
  • It did better than Flomax, etc.:
  • Reference

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