ARTICLE OYSTERS
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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.
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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:
- OMI: Occlusion MI
- STEMI criteria miss about 1/3 of cases of occlusion MI that would benefit from emergent reperfusion.
- Reference
- 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
TESTING STRATEGIES
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Overtesting and the Law of Diminishing Returns: why we shouldn’t do additional tests if the risk is already less than 1-2%
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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