The following articles are potential practice changers that for some reason never got the publicity they may have deserved (they have not enjoyed the limelight). Read my summaries, or better yet read the articles, and make your own decisions.
ACLS / RESUSCITATION:
- V-fib: meds don’t work for V-fib:
- Amiodarone = lidocaine = placebo for shock resistant V-fib
- V-tach: if giving meds, give early, preferably w/in 8 minutes
- Avoid empiric Calcium: It is class III and does more harm than good in most patients. Why are we still giving it?
- Efficacy of emergency department calcium administration in cardiac arrest: A 9-year retrospective evaluation
- COCA (Calcium-Out-of-hospital-Cardiac-Arrest) trial showed ~50% worse neuro outcomes, wastes time
- Avoid empiric Bicarb: It is class III and does more harm than good in most patients. Why are we still giving it?
- Pediatric ~60% worse neuro outcomes: Reference
- Meta Analysis
- Systematic Review,
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:
- ACS: HEART Score shortcomings
- HEART Score offers psychological comfort to providers but has poor reliability with sensitivity as low at 93% and is worse than clinical gestalt…
- Reference
- 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
- ACS: D-dimer more sensitive than troponin for unstable angina and early in MI
- Troponin rises after hours in MI and usually doesn’t rise at all in unstable angina.
- D-dimer rises earlier and is 96% sensitive in MI. D-dimer is positive in ~65% of unstable angina
- Pitfalls: not universally accepted/known, overuse could lead to unnecessary CT chest, 35% false negative
- Reference
EAR, NOSE & THROAT:
- Vertigo: steroids beneficial for vestibular neuronitis:
- Steroids led to more rapid recovery in viral causes of vertigo.
- Reference
GI/GYN:
- Vaginal Bleeding: Transfusion overused and iron underprescribed.
- Hemoperitoneum: pain may be mild and described as “bloating.” Rebound tenderness is often absent
HEMATOLOGY:
- 2/3 of massive PE’s are painless: Small PE’s cause peripheral lung infarcts and so are more likely to have pain, which is always pleuritic, and nothing else and therefore can mimic pleurisy, URI, etc. Massive PE’s are central w/o lung infarct and so are painless in 2/3 and may mimic ACS (SOB, ECG changes, troponin leak), pneumonia (WBC high, vitals abnormal), anxiety, CHF, etc. When massive PE’s do cause pain it is typically from RV ischemia and therefore not pleuritic but can also be from smaller PE fragments. Reference
INFECTIOUS DISEASE:
- Antibiotics for Diarrhea: most adults with diarrhea who are ill enough to come to the ED should go home with a script for azithromycin. The shadow literature supports this approach though few doctors do it because they want a stool culture, which typically should only be ordered in patients who have failed first line therapy or who work in the food industry or are sick enough to be hospitalized. The drug of choice used to be Cipro, but with quinolones on the out, the drug the is IN is azithromycIN. Children are much more likely to have a viral cause and so should not receive empiric antibiotics unless cultures are positive. Literature is mixed here however with many guidelines recommending against empiric antibiotics unless the case is “severe”.
- Jolt Sign in Meningitis: Is 70-100% sensitive for meningitis so should be done on anyone with fever and headache, especially if vomiting. It is not perfect but it is much better than neck stiffness, Kernig’s or Brudzinski, all of which are less sensitive (see below). Reference 1, Reference 2
- Kernig sign: 5% sensitive
- Brudzinki sign: 5% sensitive
- Nuchal rigidity: 30% sensitive
- Photophobia: probably ~30% sensitive
- Jolt accentuation: 70-99% sensitive
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:
- YEARS criteria limits need for CT or VQ in mild D-dimer elevations – VALIDATED
- Included: 3616 patients to determine when can use a higher D-dimer cutoff (double the usual one)
- Excluded: age <18, blood thinner use
- No clinical signs of DVT
- No better Alternate diagnosis
- No Hemoptysis
- Benefit: Using a D-dimer cutoff of twice usual cutoff led to 14% fewer chest CT”s. ~99% sensitive. Better than age-adjusted unless your patient is older than 100, validated in pregnant patient and those under age 50 where radiation may be more of a concern.
- More info: 1) Lancet. 2017; 390:289-297: 2) https://rebelem.com/the-years-study
- Age Adjusted D-dimer limits need for CT or VQ in mild D-dimer elevations – VALIDATED
- Basically if your patient is 60 you can use 600 for a d-dimer cutoff if the usual cutoff is 500. If they are 80 you can use 800
- MDcalc page
- Pneumonia: steroids beneficial for admitted pneumonia (not just COVID or COPD/Asthma):
- 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. 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.
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:
-
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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