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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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